Provider Demographics
NPI:1881843068
Name:VANKIRK, JOHN ELLSWORTH (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ELLSWORTH
Last Name:VANKIRK
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 1:235 AMHERST AVE
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94402-2201
Mailing Address - Country:US
Mailing Address - Phone:650-342-1118
Mailing Address - Fax:650-579-2850
Practice Address - Street 1:235 AMHERST AVE
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94402-2201
Practice Address - Country:US
Practice Address - Phone:650-342-1118
Practice Address - Fax:650-579-2850
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-12
Last Update Date:2008-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG24833207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA42413Medicare UPIN