Provider Demographics
NPI:1669537197
Name:VANDYCK, PETER FRANDSEN (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:FRANDSEN
Last Name:VANDYCK
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 1:3320 OLD JEFFERSON RD STE 300A
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30607-1442
Mailing Address - Country:US
Mailing Address - Phone:706-549-4155
Mailing Address - Fax:706-546-0036
Practice Address - Street 1:3320 OLD JEFFERSON RD
Practice Address - Street 2:BUILDING 600
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30607-1400
Practice Address - Country:US
Practice Address - Phone:706-549-4155
Practice Address - Fax:706-546-0036
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA27679207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00384997BMedicaid
GA52022022OtherBLUE CROSS
GA52022022OtherBLUE CROSS
GA00384997BMedicaid