Provider Demographics
NPI:1336210061
Name:FLETCHER, VANCE LAIDLAW (MD)
Entity Type:Individual
Prefix:DR
First Name:VANCE
Middle Name:LAIDLAW
Last Name:FLETCHER
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 1:91275 66TH AVE
Mailing Address - Street 2:
Mailing Address - City:MECCA
Mailing Address - State:CA
Mailing Address - Zip Code:92254-1251
Mailing Address - Country:US
Mailing Address - Phone:760-396-1249
Mailing Address - Fax:760-396-1253
Practice Address - Street 1:91275 66TH AVE
Practice Address - Street 2:
Practice Address - City:MECCA
Practice Address - State:CA
Practice Address - Zip Code:92254-1251
Practice Address - Country:US
Practice Address - Phone:760-396-1249
Practice Address - Fax:760-396-1253
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC186960207QA0505X
HI13964207QA0505X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I20339Medicare UPIN
HIH102318Medicare PIN