Provider Demographics
NPI:1972698132
Name:VANDYKE, RUSSELL BARRETT (MD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:BARRETT
Last Name:VANDYKE
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 1:1430 TULANE AVE
Mailing Address - Street 2:TB 8
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70112-2632
Mailing Address - Country:US
Mailing Address - Phone:504-988-5422
Mailing Address - Fax:504-988-3805
Practice Address - Street 1:1415 TULANE AVE
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70112-2600
Practice Address - Country:US
Practice Address - Phone:504-988-2300
Practice Address - Fax:504-988-7654
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2012-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA06179R2080P0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0208XAllopathic & Osteopathic PhysiciansPediatricsPediatric Infectious Diseases
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1332691Medicaid
LA1332691Medicaid
LA4M623Medicare PIN