Healthcare Provider Details

I. General information

NPI: 1528033578
Provider Name (Legal Business Name): GLEN E VANDER ZALM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2006
Last Update Date: 03/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3885 OAKWATER CIR
ORLANDO FL
32806-6257
US

IV. Provider business mailing address

3885 OAKWATER CIR
ORLANDO FL
32806-6257
US

V. Phone/Fax

Practice location:
  • Phone: 407-851-5600
  • Fax: 407-438-9585
Mailing address:
  • Phone: 470-851-5600
  • Fax: 407-438-9585

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberME91815
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: