1932202579 NPI number — JP VANDONGEN, MD, PA

Table of content: (NPI 1932202579)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932202579 NPI number — JP VANDONGEN, MD, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JP VANDONGEN, MD, PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1932202579
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/10/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
599 9TH ST N
Provider Second Line Business Mailing Address:
#308
Provider Business Mailing Address City Name:
NAPLES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34102-5627
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-643-7888
Provider Business Mailing Address Fax Number:
239-643-4744

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
599 9TH ST N
Provider Second Line Business Practice Location Address:
#308
Provider Business Practice Location Address City Name:
NAPLES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34102-5627
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-643-7888
Provider Business Practice Location Address Fax Number:
239-643-4744
Provider Enumeration Date:
09/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
VAN DONGEN
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
P
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
239-643-7888

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  ME73716 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207R00000X , with the licence number: ME127276 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 5727534 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 01-90398 . This is a "OHC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 255617100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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