Provider Demographics
NPI:1225005192
Name:VANDYKE, JOHN JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:JOSEPH
Last Name:VANDYKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:959 E WALNUT ST
Mailing Address - Street 2:SUITE 120
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91106-1451
Mailing Address - Country:US
Mailing Address - Phone:626-795-5118
Mailing Address - Fax:626-795-2716
Practice Address - Street 1:959 E WALNUT ST
Practice Address - Street 2:SUITE 120
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91106-1451
Practice Address - Country:US
Practice Address - Phone:626-795-5118
Practice Address - Fax:626-795-2716
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2012-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA20717207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A207170Medicaid
CA00A207170Medicaid
CAW481Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER