Provider Demographics
NPI:1376568204
Name:VANDERBURG, EDWARD JASON (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:JASON
Last Name:VANDERBURG
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 1:6015 CHENONCEAU BLVD STE 140
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72223-4584
Mailing Address - Country:US
Mailing Address - Phone:501-868-8410
Mailing Address - Fax:501-868-8488
Practice Address - Street 1:6015 CHENONCEAU BLVD STE 140
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72223-4584
Practice Address - Country:US
Practice Address - Phone:501-868-8410
Practice Address - Fax:501-868-8488
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE4348207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR162281001Medicaid
ARI61691Medicare UPIN
AR57297Medicare PIN
AR5N637Medicare PIN
AR162281001Medicaid