Provider Demographics
NPI:1558343137
Name:VANDEWATER, JAMES C (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:C
Last Name:VANDEWATER
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:PO BOX 2489
Mailing Address - Street 2:
Mailing Address - City:FOREST
Mailing Address - State:VA
Mailing Address - Zip Code:24551-6489
Mailing Address - Country:US
Mailing Address - Phone:434-382-1139
Mailing Address - Fax:434-525-5748
Practice Address - Street 1:20304 TIMBERLAKE RD
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24502-7222
Practice Address - Country:US
Practice Address - Phone:434-237-6471
Practice Address - Fax:434-237-8810
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101027927207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA066023OtherANTHEM
VA080140296OtherMEDICARE RAILROAD
VA005601665Medicaid
VARETIREDOtherRETIRED 05/02/2013
VA066023OtherANTHEM
VARETIREDOtherRETIRED 05/02/2013