Provider Demographics
NPI:1811076714
Name:VANNYNATTEN, FRED H (MD)
Entity type:Individual
Prefix:DR
First Name:FRED
Middle Name:H
Last Name:VANNYNATTEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:FRED
Other - Middle Name:H
Other - Last Name:VAN NYNATTEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1990 S 16TH ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-6647
Mailing Address - Country:US
Mailing Address - Phone:910-762-7071
Mailing Address - Fax:910-762-9658
Practice Address - Street 1:1990 S 16TH ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-6647
Practice Address - Country:US
Practice Address - Phone:910-762-7071
Practice Address - Fax:910-762-9658
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC19777207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890296HMedicaid
NC890296HMedicaid