Provider Demographics
NPI:1528025988
Name:VREDENBURG, MARY JANE (DO)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JANE
Last Name:VREDENBURG
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1235 W VINE ST
Mailing Address - Street 2:SUITE 20
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-5144
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1235 W VINE ST
Practice Address - Street 2:SUITE 20
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-5144
Practice Address - Country:US
Practice Address - Phone:209-339-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2009-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7374207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX73740Medicaid
CAG48260Medicare UPIN
CA00AX73740Medicaid