Provider Demographics
NPI:1467452243
Name:VANAUSDAL, PAUL F (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:F
Last Name:VANAUSDAL
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 1:1425 XENIA AVE
Mailing Address - Street 2:
Mailing Address - City:YELLOW SPRINGS
Mailing Address - State:OH
Mailing Address - Zip Code:45387-1121
Mailing Address - Country:US
Mailing Address - Phone:937-767-7291
Mailing Address - Fax:937-767-1302
Practice Address - Street 1:1425 XENIA AVE
Practice Address - Street 2:
Practice Address - City:YELLOW SPRINGS
Practice Address - State:OH
Practice Address - Zip Code:45387-1121
Practice Address - Country:US
Practice Address - Phone:937-767-7291
Practice Address - Fax:937-767-1302
Is Sole Proprietor?:No
Enumeration Date:2005-07-22
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35036419207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000025526OtherANTHEM
OH0400337Medicaid
A79169Medicare UPIN
OH0471382Medicare PIN