Provider Demographics
NPI:1558401398
Name:VANGORKUM, DARIAN JERALD (DPM)
Entity Type:Individual
Prefix:DR
First Name:DARIAN
Middle Name:JERALD
Last Name:VANGORKUM
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:925 STEVENS DR
Mailing Address - Street 2:STE 2D
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352-3523
Mailing Address - Country:US
Mailing Address - Phone:509-946-7602
Mailing Address - Fax:509-943-9389
Practice Address - Street 1:750 SWIFT BLVD
Practice Address - Street 2:STE 2
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352
Practice Address - Country:US
Practice Address - Phone:509-946-7602
Practice Address - Fax:509-943-9389
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPO00000620213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0480830001OtherDEMERC
WA1104231Medicaid
WA122647OtherL AND I
0480830001OtherDEMERC
319210400Medicare ID - Type Unspecified
WA122647OtherL AND I