Provider Demographics
NPI:1811986094
Name:VANDEREN, JOHN M III (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:M
Last Name:VANDEREN
Suffix:III
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 2379
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41105-2379
Mailing Address - Country:US
Mailing Address - Phone:606-324-4745
Mailing Address - Fax:606-324-4941
Practice Address - Street 1:613 23RD ST
Practice Address - Street 2:STE 230
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-2876
Practice Address - Country:US
Practice Address - Phone:606-324-4745
Practice Address - Fax:606-324-4941
Is Sole Proprietor?:No
Enumeration Date:2005-10-19
Last Update Date:2014-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY27105207RC0000X, 207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2138252Medicaid
WV6020006000Medicaid
KY64271059Medicaid
KY000000065461OtherANTHEM BCBS
OH2138252Medicaid
E67791Medicare UPIN