Provider Demographics
NPI:1790743847
Name:VANN, JOHN RANDOLPH (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:RANDOLPH
Last Name:VANN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:803-434-6485
Mailing Address - Fax:864-675-1657
Practice Address - Street 1:11 PARK CREEK DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4270
Practice Address - Country:US
Practice Address - Phone:864-234-7654
Practice Address - Fax:864-675-1657
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10571207X00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC105718Medicaid
SC105718Medicaid
SCC47039Medicare UPIN