Provider Demographics
NPI:1619951894
Name:VANDUSEN, FREDERICK PAUL (DO)
Entity Type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:PAUL
Last Name:VANDUSEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 CN MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:GALENA
Mailing Address - State:MD
Mailing Address - Zip Code:21635
Mailing Address - Country:US
Mailing Address - Phone:410-648-5150
Mailing Address - Fax:410-648-5140
Practice Address - Street 1:119 C N MAIN STREET
Practice Address - Street 2:
Practice Address - City:GALENA
Practice Address - State:MD
Practice Address - Zip Code:21635
Practice Address - Country:US
Practice Address - Phone:410-648-5150
Practice Address - Fax:410-648-5140
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC20004063207Q00000X
MDH67200207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD442259700Medicaid
DE0001067004Medicaid
MD5391600OtherAETNA
MD521116591OtherINFORMED
MD8177823OtherUNITED HEALTHCARE/MAMSI/OPT CHOICE
MD038396OtherPRIORITY PARTNERS
MD442259700Medicaid
DE0001067004Medicaid