Provider Demographics
NPI:1568435659
Name:VANDIEPEN, PATRICIA GAIL (DO)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:GAIL
Last Name:VANDIEPEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:279 S YONGE ST
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-6257
Mailing Address - Country:US
Mailing Address - Phone:386-673-2133
Mailing Address - Fax:386-673-2743
Practice Address - Street 1:279 S YONGE ST
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-6257
Practice Address - Country:US
Practice Address - Phone:386-673-2133
Practice Address - Fax:386-673-2743
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7544207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL57583OtherBCBS NUMBER
FL567660OtherAETNA NUMBER
FLP00096989OtherRRMEDICARE
FLP00096989OtherRRMEDICARE
FLG65722Medicare UPIN