Provider Demographics
NPI:1528044393
Name:VENDRELL, MICHAEL J (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:VENDRELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4220 HERSCHEL AVE
Mailing Address - Street 2:APT 809
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75219-2380
Mailing Address - Country:US
Mailing Address - Phone:651-245-3950
Mailing Address - Fax:
Practice Address - Street 1:4411 THE 25 WAY NE
Practice Address - Street 2:#150
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-5857
Practice Address - Country:US
Practice Address - Phone:651-245-3950
Practice Address - Fax:413-643-4773
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2017-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN441272085R0202X
WAMD000473082085R0202X
NM80-2782085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN662665300Medicaid
MN662665300Medicaid
C98227Medicare UPIN