Provider Demographics
NPI:1720044365
Name:VANDIVORT, MONICA R (MD)
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:R
Last Name:VANDIVORT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:599 E WILCOX DR
Mailing Address - Street 2:
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85635-2531
Mailing Address - Country:US
Mailing Address - Phone:520-459-4604
Mailing Address - Fax:520-459-4603
Practice Address - Street 1:599 E WILCOX DR
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-2531
Practice Address - Country:US
Practice Address - Phone:520-459-4604
Practice Address - Fax:520-458-2444
Is Sole Proprietor?:No
Enumeration Date:2006-04-22
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ26972207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ445230Medicaid
F86993Medicare UPIN
AZ445230Medicaid