Provider Demographics
NPI:1851591127
Name:VANDERVELDT, GARIG (MD)
Entity Type:Individual
Prefix:
First Name:GARIG
Middle Name:
Last Name:VANDERVELDT
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 1:2020 21ST AVE S STE 201
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37212-4354
Mailing Address - Country:US
Mailing Address - Phone:615-269-0652
Mailing Address - Fax:
Practice Address - Street 1:651 DUNLOP LN
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040-5015
Practice Address - Country:US
Practice Address - Phone:931-502-1370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-24
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD433267207P00000X
CAA100183207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3001449Medicaid
CA0A1001830Medicaid
TN3001449Medicaid
CA00A1001830Medicare PIN