Provider Demographics
NPI:1457340291
Name:VANDERBILT, DOUGLAS L II (MD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:L
Last Name:VANDERBILT
Suffix:II
Gender:M
Credentials:MD
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Mailing Address - Street 1:6430 W SUNSET BLVD
Mailing Address - Street 2:SUITE 600
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90028-7900
Mailing Address - Country:US
Mailing Address - Phone:323-361-2337
Mailing Address - Fax:323-361-8491
Practice Address - Street 1:4650 W SUNSET BLVD
Practice Address - Street 2:MS#76
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-6062
Practice Address - Country:US
Practice Address - Phone:617-414-5170
Practice Address - Fax:323-361-8566
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2009-07-24
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Provider Licenses
StateLicense IDTaxonomies
MA2135492080P0006X
CAA751232080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0179540Medicaid
A34592Medicare ID - Type Unspecified
MA0179540Medicaid