Provider Demographics
NPI:1740321579
Name:VANDERHOOF, BRIAN STEPHEN (DO)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:STEPHEN
Last Name:VANDERHOOF
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2400 WISTERIA DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-2689
Mailing Address - Country:US
Mailing Address - Phone:770-985-9330
Mailing Address - Fax:770-978-9455
Practice Address - Street 1:2400 WISTERIA DR
Practice Address - Street 2:SUITE A
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-2689
Practice Address - Country:US
Practice Address - Phone:770-985-9330
Practice Address - Fax:770-978-9455
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA038391204C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00665695AMedicaid
GAG11669Medicare UPIN
GA00665695AMedicaid