Provider Demographics
NPI:1750323630
Name:VANDIVER, WILLIAM RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:RICHARD
Last Name:VANDIVER
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 1:108 E US HIGHWAY 80 STE 150
Mailing Address - Street 2:
Mailing Address - City:FORNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75126-8703
Mailing Address - Country:US
Mailing Address - Phone:972-564-4444
Mailing Address - Fax:833-320-1559
Practice Address - Street 1:108 E. US HWY HWY 80 SUITE 150
Practice Address - Street 2:
Practice Address - City:FORNEY
Practice Address - State:TX
Practice Address - Zip Code:75126-8703
Practice Address - Country:US
Practice Address - Phone:972-564-4444
Practice Address - Fax:833-320-1559
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK9195207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX82V196OtherBCBS
TX040025101Medicaid
TX200038519Medicare PIN
TX82V196OtherBCBS
TX040025101Medicaid
TX200036204Medicare PIN
TX419963YKQLMedicare PIN
TX200036205Medicare PIN
TX419963YKP5Medicare PIN