Provider Demographics
NPI:1093817355
Name:VANDORN, MICHELLE M (DO)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:M
Last Name:VANDORN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4315 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62226-5342
Mailing Address - Country:US
Mailing Address - Phone:618-257-6220
Mailing Address - Fax:
Practice Address - Street 1:4315 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226-5342
Practice Address - Country:US
Practice Address - Phone:618-257-6220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2020-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-107561207P00000X, 207R00000X
IL036107561207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1093817355Medicaid
IL036107561Medicaid
ILIL3374060Medicare PIN
MO1093817355Medicaid