Provider Demographics
NPI:1558367623
Name:VANDENBERG, TODD L (MD)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:L
Last Name:VANDENBERG
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 1:330 SEVEN SPRINGS WAY
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5098
Mailing Address - Country:US
Mailing Address - Phone:615-920-7878
Mailing Address - Fax:615-920-8775
Practice Address - Street 1:222 E MEDICAL LN STE 101
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-4850
Practice Address - Country:US
Practice Address - Phone:803-739-3660
Practice Address - Fax:803-739-3663
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC20877208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC340017144OtherRAILROAD MEDICARE
SC208778Medicaid
SC1904812OtherPHP
SC208778Medicaid