Provider Demographics
NPI:1770787400
Name:VANDERFORD, JOEL LEONARD
Entity type:Individual
Prefix:DR
First Name:JOEL
Middle Name:LEONARD
Last Name:VANDERFORD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 STANTONSBURG RD
Mailing Address - Street 2:PCMH GRADUATE MEDICAL EDUCATION
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-2818
Mailing Address - Country:US
Mailing Address - Phone:252-847-4268
Mailing Address - Fax:
Practice Address - Street 1:2100 STANTONSBURG RD
Practice Address - Street 2:PCMH GRADUATE MEDICAL EDUCATION
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-2818
Practice Address - Country:US
Practice Address - Phone:252-847-4268
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ546412080P0203X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ300867Medicaid