Provider Demographics
NPI:1336295963
Name:VANDERVEST, KATHERINE (MD)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:VANDERVEST
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3410 WORTH ST.
Mailing Address - Street 2:SUITE 250
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75246
Mailing Address - Country:US
Mailing Address - Phone:214-820-2346
Mailing Address - Fax:215-820-9818
Practice Address - Street 1:3410 WORTH ST.
Practice Address - Street 2:SUITE 250
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246
Practice Address - Country:US
Practice Address - Phone:214-820-2346
Practice Address - Fax:215-820-9818
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO46486207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO81556837Medicaid
COCOAAA0760Medicare PIN