Provider Demographics
NPI:1710554522
Name:VONDRELL, DOUGLAS PATRICK
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:PATRICK
Last Name:VONDRELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3090 YOAKAM RD
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45806-1144
Mailing Address - Country:US
Mailing Address - Phone:567-204-4365
Mailing Address - Fax:
Practice Address - Street 1:3090 YOAKAM RD
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45806-1144
Practice Address - Country:US
Practice Address - Phone:567-204-4365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-09
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH910001044390Medicaid