Healthcare Provider Details

I. General information

NPI: 1447290630
Provider Name (Legal Business Name): JOHN A. VANDE WAA DO, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 05/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2451 FILLINGIM ST MASTIN BLDG
MOBILE AL
36617-2238
US

IV. Provider business mailing address

PO BOX 40480
MOBILE AL
36640-0480
US

V. Phone/Fax

Practice location:
  • Phone: 251-470-5890
  • Fax: 251-471-7925
Mailing address:
  • Phone: 251-470-5890
  • Fax: 251-471-7925

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberDO-401
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: