Provider Demographics
NPI:1346202470
Name:VANDERPOOL, EVERETT JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:EVERETT
Middle Name:JOHN
Last Name:VANDERPOOL
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 9142
Mailing Address - Street 2:MASS GENERAL PHYSICIAN ORGANIZATION
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-9142
Mailing Address - Country:US
Mailing Address - Phone:617-724-0287
Mailing Address - Fax:617-726-2894
Practice Address - Street 1:300 OCEAN AVE
Practice Address - Street 2:REVERE HEALTHCARE CENTER
Practice Address - City:REVERE
Practice Address - State:MA
Practice Address - Zip Code:02151-3675
Practice Address - Country:US
Practice Address - Phone:781-485-6316
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA202747207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA202747OtherTUFTS HEALTH PLAN
MA0107760Medicaid
MAJ22872OtherBCBS MA
G61937Medicare UPIN
MAA31866Medicare ID - Type Unspecified