Provider Demographics
NPI:1578623690
Name:VANDER HEYDEN, JOHN L (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:L
Last Name:VANDER HEYDEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4361 TALBOT RD S
Mailing Address - Street 2:112
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98055-6226
Mailing Address - Country:US
Mailing Address - Phone:425-255-5111
Mailing Address - Fax:425-254-0985
Practice Address - Street 1:4361 TALBOT RD S
Practice Address - Street 2:112
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-6226
Practice Address - Country:US
Practice Address - Phone:425-255-5111
Practice Address - Fax:425-254-0985
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00017646207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1023365Medicaid
WA1023365Medicaid
WAAB29074Medicare ID - Type Unspecified