Provider Demographics
NPI:1336451624
Name:VANDERLOO, JOHN PFH (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:PFH
Last Name:VANDERLOO
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:3000 OLD CANTON RD
Mailing Address - Street 2:STE 240
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4235
Mailing Address - Country:US
Mailing Address - Phone:601-228-5491
Mailing Address - Fax:601-429-9297
Practice Address - Street 1:3000 OLD CANTON RD
Practice Address - Street 2:STE 240
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4235
Practice Address - Country:US
Practice Address - Phone:601-228-5491
Practice Address - Fax:601-429-9297
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-02
Last Update Date:2020-04-06
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MS21905207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00270041Medicaid
MSP01402433OtherRR MEDICARE
MS00270041Medicaid