Provider Demographics
NPI:1629039698
Name:VANFOSSEN, DOUGLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:
Last Name:VANFOSSEN
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:PO BOX 7527
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43017-0727
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:260 POLARIS PKWY FL 2
Practice Address - Street 2:
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43082-8019
Practice Address - Country:US
Practice Address - Phone:614-533-3470
Practice Address - Fax:614-533-3160
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.046445207RI0011X, 207RC0000X
OH35046445174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0554967Medicaid
OH0554967Medicaid
OHC03156Medicare UPIN