Provider Demographics
NPI:1417090770
Name:VANDIVER, ROBERT EUGENE II (PA)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:EUGENE
Last Name:VANDIVER
Suffix:II
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:139 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WILBURTON
Mailing Address - State:OK
Mailing Address - Zip Code:74578-4229
Mailing Address - Country:US
Mailing Address - Phone:918-465-5727
Mailing Address - Fax:918-465-3311
Practice Address - Street 1:139 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WILBURTON
Practice Address - State:OK
Practice Address - Zip Code:74578-4229
Practice Address - Country:US
Practice Address - Phone:918-465-5727
Practice Address - Fax:918-465-3311
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2007-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK527363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1417090770OtherNPI
OK373876Medicare Oscar/Certification