Provider Demographics
NPI:1225012008
Name:VANDERBERG, DWAYNE P (MD)
Entity Type:Individual
Prefix:
First Name:DWAYNE
Middle Name:P
Last Name:VANDERBERG
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:PO BOX A D
Mailing Address - Street 2:
Mailing Address - City:YUBA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95992-1396
Mailing Address - Country:US
Mailing Address - Phone:530-751-3769
Mailing Address - Fax:530-751-1237
Practice Address - Street 1:4941 OLIVEHURST AVE
Practice Address - Street 2:
Practice Address - City:OLIVEHURST
Practice Address - State:CA
Practice Address - Zip Code:95961-4225
Practice Address - Country:US
Practice Address - Phone:530-743-4611
Practice Address - Fax:530-743-5770
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2011-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG73626207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F92539Medicare UPIN