Provider Demographics
NPI:1417043852
Name:VANAALST, JOHN ANANDA (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ANANDA
Last Name:VANAALST
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 1:12667 GREEN RD
Mailing Address - Street 2:
Mailing Address - City:WALTON
Mailing Address - State:KY
Mailing Address - Zip Code:41094-8731
Mailing Address - Country:US
Mailing Address - Phone:919-818-3377
Mailing Address - Fax:
Practice Address - Street 1:10200 FOREST GREEN BLVD STE 112
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40223-5167
Practice Address - Country:US
Practice Address - Phone:954-399-4673
Practice Address - Fax:513-636-7182
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.0698102086S0122X
KY501022086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0111752Medicaid
KY7100358000Medicaid