Provider Demographics
NPI:1245432772
Name:VANDEMOER, J NICHOLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:J
Middle Name:NICHOLAS
Last Name:VANDEMOER
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 1:68 CAMP ST
Mailing Address - Street 2:
Mailing Address - City:HYANNIS
Mailing Address - State:MA
Mailing Address - Zip Code:02601-3048
Mailing Address - Country:US
Mailing Address - Phone:508-775-7026
Mailing Address - Fax:
Practice Address - Street 1:49 LAKESIDE DR E
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02632-1834
Practice Address - Country:US
Practice Address - Phone:508-771-8017
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-05
Last Update Date:2019-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA36521174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2021455Medicaid
MA2021455Medicaid
MAA59759Medicare UPIN