Provider Demographics
NPI:1972859114
Name:VANDEVEN, THOMAS CARMINE (DO)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:CARMINE
Last Name:VANDEVEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:819 S 13TH ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-4112
Mailing Address - Country:US
Mailing Address - Phone:360-814-6230
Mailing Address - Fax:
Practice Address - Street 1:819 S 13TH ST
Practice Address - Street 2:SRC RESIDENCY CLINIC
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98274-4112
Practice Address - Country:US
Practice Address - Phone:360-814-6230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-25
Last Update Date:2013-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60297543207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine