Provider Demographics
NPI:1679657985
Name:VANDERBILT, JOHN J JR (MPT)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:J
Last Name:VANDERBILT
Suffix:JR
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2700 KLAMATH DR
Mailing Address - Street 2:
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95765-5202
Mailing Address - Country:US
Mailing Address - Phone:916-879-7867
Mailing Address - Fax:916-435-4970
Practice Address - Street 1:107 S HARDING BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95678-3354
Practice Address - Country:US
Practice Address - Phone:916-879-7867
Practice Address - Fax:916-435-4970
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0PT24958225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT0249580Medicaid
CAPT0249580Medicaid
CAZZZ013682Medicare ID - Type Unspecified
CA030502878Medicare UPIN