Provider Demographics
NPI:1790733475
Name:VANDIVER, CAROLYN JILL (MD)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:JILL
Last Name:VANDIVER
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 1:1750 NORTH HAMPTON ROAD
Mailing Address - Street 2:
Mailing Address - City:DESOTO
Mailing Address - State:TX
Mailing Address - Zip Code:75115-2306
Mailing Address - Country:US
Mailing Address - Phone:214-946-4397
Mailing Address - Fax:214-946-4399
Practice Address - Street 1:1750 NORTH HAMPTON ROAD
Practice Address - Street 2:
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-2306
Practice Address - Country:US
Practice Address - Phone:214-946-4397
Practice Address - Fax:214-946-4399
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK85482085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX104934803Medicaid
G79487Medicare UPIN
TX8C8615Medicare PIN
TX104934803Medicaid
TX8G7763Medicare PIN