Provider Demographics
NPI:1851737373
Name:STEVEN J VANDERBY MD P.A.
Entity Type:Organization
Organization Name:STEVEN J VANDERBY MD P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:VANDERBY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-725-8222
Mailing Address - Street 1:4030 MINTON RD
Mailing Address - Street 2:
Mailing Address - City:W MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-9559
Mailing Address - Country:US
Mailing Address - Phone:321-725-8222
Mailing Address - Fax:321-676-2299
Practice Address - Street 1:4030 MINTON RD
Practice Address - Street 2:
Practice Address - City:W MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-9559
Practice Address - Country:US
Practice Address - Phone:321-725-8222
Practice Address - Fax:321-676-2299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-13
Last Update Date:2013-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0059801207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLA74018Medicare PIN