Provider Demographics
NPI:1912122680
Name:VANDENBERG, GARY (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:VANDENBERG
Suffix:
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 1:9834 GENESEE AVE
Mailing Address - Street 2:SUITE 326
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-1223
Mailing Address - Country:US
Mailing Address - Phone:858-453-3813
Mailing Address - Fax:858-453-1727
Practice Address - Street 1:9834 GENESEE AVE
Practice Address - Street 2:SUITE 326
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1223
Practice Address - Country:US
Practice Address - Phone:858-453-3813
Practice Address - Fax:858-453-1727
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC33053173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC33053Medicare ID - Type UnspecifiedCALIFORNIA STATE LICENSE