Provider Demographics
NPI:1790779247
Name:VANDERHEIDEN, DAVID LOYD I (DO)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:LOYD
Last Name:VANDERHEIDEN
Suffix:I
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4818 HOLLY RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78411-4734
Mailing Address - Country:US
Mailing Address - Phone:361-993-1747
Mailing Address - Fax:361-993-1748
Practice Address - Street 1:4818 HOLLY RD
Practice Address - Street 2:SUITE A
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411-4734
Practice Address - Country:US
Practice Address - Phone:361-993-1747
Practice Address - Fax:361-993-1748
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-09
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXH8480207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX114951003Medicaid
TX88T881OtherBLUE CROSS BLUE SHIELD
TX114951003Medicaid
TXF23495Medicare UPIN