Provider Demographics
NPI:1538109160
Name:VANDERVELDT, STEPHANIE L (MD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:L
Last Name:VANDERVELDT
Suffix:
Gender:F
Credentials:MD
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Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1100 JOHNSON FERRY RD NE
Mailing Address - Street 2:SUITE 593
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1709
Mailing Address - Country:US
Mailing Address - Phone:404-255-9096
Mailing Address - Fax:404-255-9097
Practice Address - Street 1:1100 JOHNSON FERRY RD NE
Practice Address - Street 2:SUITE 593
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1709
Practice Address - Country:US
Practice Address - Phone:404-255-9096
Practice Address - Fax:404-255-9097
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2023-04-05
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA61013207W00000X
FLME95854207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA61013OtherGEORGIA COMPOSITE MEDICAL BOARD