Provider Demographics
NPI:1528033578
Name:VANDER ZALM, GLEN E (MD)
Entity Type:Individual
Prefix:DR
First Name:GLEN
Middle Name:E
Last Name:VANDER ZALM
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 1:3885 OAKWATER CIR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-6257
Mailing Address - Country:US
Mailing Address - Phone:470-851-5600
Mailing Address - Fax:407-438-9585
Practice Address - Street 1:3885 OAKWATER CIR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-6257
Practice Address - Country:US
Practice Address - Phone:407-851-5600
Practice Address - Fax:407-438-9585
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2011-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME91815207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL61788OtherBC/BS
FL271650000Medicaid
FL3743151OtherAETNA
FL61788YMedicare PIN
FL61788ZMedicare PIN
FLE92179Medicare UPIN
FL61788OtherBC/BS
FL271650000Medicaid