Provider Demographics
NPI:1366462368
Name:VANDERMOLEN, DAVID THEODORE (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:THEODORE
Last Name:VANDERMOLEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2401 GREENWOOD RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-4010
Mailing Address - Country:US
Mailing Address - Phone:318-841-5800
Mailing Address - Fax:318-841-5817
Practice Address - Street 1:2401 GREENWOOD RD
Practice Address - Street 2:SUITE A
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4010
Practice Address - Country:US
Practice Address - Phone:318-841-5800
Practice Address - Fax:318-841-5817
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2020-04-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA12977R207VE0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VE0102XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyReproductive Endocrinology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1551767Medicaid
LA1551767Medicaid
LA5E365F600Medicare ID - Type Unspecified