Provider Demographics
NPI:1730299660
Name:VANANTWERP, RANDY L (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:L
Last Name:VANANTWERP
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 140987
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99514-0987
Mailing Address - Country:US
Mailing Address - Phone:907-345-0004
Mailing Address - Fax:907-561-1953
Practice Address - Street 1:2801 DEBARR RD
Practice Address - Street 2:DEPARTMENT OF PATHOLOGY
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-2932
Practice Address - Country:US
Practice Address - Phone:907-264-1171
Practice Address - Fax:907-264-1702
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK3473207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD1801Medicaid
AKGRO825Medicaid
AKK0000WCJJXMedicare ID - Type UnspecifiedMEDICARE PROVIDER #
AKE84378Medicare UPIN
AKGRO825Medicaid