Provider Demographics
NPI:1306355714
Name:GARY VANDENBERG,JR., M.D.,INC.
Entity Type:Organization
Organization Name:GARY VANDENBERG,JR., M.D.,INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:VANDENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-453-3813
Mailing Address - Street 1:9834 GENESEE AVE STE 326
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-1216
Mailing Address - Country:US
Mailing Address - Phone:858-453-3813
Mailing Address - Fax:858-453-1727
Practice Address - Street 1:9834 GENESEE AVE STE 326
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1216
Practice Address - Country:US
Practice Address - Phone:858-453-3813
Practice Address - Fax:858-453-1727
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC33053261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC33053OtherM.D.