Provider Demographics
NPI:1700997871
Name:DELAND FAMILY MEDICINE PA
Entity Type:Organization
Organization Name:DELAND FAMILY MEDICINE PA
Other - Org Name:DELAND FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MELANIE
Authorized Official - Middle Name:R
Authorized Official - Last Name:VANDEMARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-740-1701
Mailing Address - Street 1:PO BOX 741240
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32774-1240
Mailing Address - Country:US
Mailing Address - Phone:386-774-5211
Mailing Address - Fax:
Practice Address - Street 1:1450 S WOODLAND BLVD
Practice Address - Street 2:SUITE 300C
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-7767
Practice Address - Country:US
Practice Address - Phone:386-740-1701
Practice Address - Fax:386-740-1798
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME912900207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLQ0182OtherMEDICARE PT AN
FL52043OtherBCBS OF FL
FLQ0182OtherMEDICARE PT AN