Provider Demographics
NPI:1609971589
Name:VANDEUSEN, LOREN MILLARD (MD)
Entity Type:Individual
Prefix:
First Name:LOREN
Middle Name:MILLARD
Last Name:VANDEUSEN
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 1:3636 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:GROVE CITY
Mailing Address - State:OH
Mailing Address - Zip Code:43123-2202
Mailing Address - Country:US
Mailing Address - Phone:614-871-3234
Mailing Address - Fax:614-871-1494
Practice Address - Street 1:3636 BROADWAY
Practice Address - Street 2:
Practice Address - City:GROVE CITY
Practice Address - State:OH
Practice Address - Zip Code:43123-2202
Practice Address - Country:US
Practice Address - Phone:614-871-3234
Practice Address - Fax:614-871-1494
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH51677207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHA82871Medicare ID - Type Unspecified