Provider Demographics
NPI:1225027907
Name:VANDELDEN, MAHLON (MD)
Entity Type:Individual
Prefix:
First Name:MAHLON
Middle Name:
Last Name:VANDELDEN
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 1:1000 W NIFONG BLVD
Mailing Address - Street 2:BUILDING 3, SUITE 100
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-5615
Mailing Address - Country:US
Mailing Address - Phone:573-214-2000
Mailing Address - Fax:573-214-2042
Practice Address - Street 1:1000 W NIFONG BLVD
Practice Address - Street 2:BUILDING 3, SUITE 100
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-5615
Practice Address - Country:US
Practice Address - Phone:573-214-2000
Practice Address - Fax:573-214-2042
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01048581A207Y00000X
KY34110207Y00000X
MO101110207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN065102OtherHEALTH ALLIANCE
INP00153580OtherRR MEDICARE
IN000000045661OtherANTHEM
KY000000045661OtherANTHEM
KY040013796OtherRR MEDICARE
KY64341019Medicaid
IN382908OtherHEALTHLINK
IN200181080AMedicaid
IN000000045661OtherANTHEM
IN065102OtherHEALTH ALLIANCE
KY000000045661OtherANTHEM