Provider Demographics
NPI:1700052008
Name:VANDERVELDT, HENDRIKUS S (MD)
Entity type:Individual
Prefix:
First Name:HENDRIKUS
Middle Name:S
Last Name:VANDERVELDT
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:PO BOX 845347
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-7208
Mailing Address - Country:US
Mailing Address - Phone:214-645-0595
Mailing Address - Fax:
Practice Address - Street 1:1801 INWOOD RD
Practice Address - Street 2:SUITE 6.102
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-9083
Practice Address - Country:US
Practice Address - Phone:214-645-0595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-06
Last Update Date:2019-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP6743207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX323906301Medicaid
TX323906302OtherCSHCN
TX297953YK00Medicare PIN