Healthcare Provider Details

I. General information

NPI: 1417043852
Provider Name (Legal Business Name): JOHN ANANDA VANAALST MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 10/25/2023
Certification Date: 10/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10200 FOREST GREEN BLVD STE 112
LOUISVILLE KY
40223-5167
US

IV. Provider business mailing address

12667 GREEN RD
WALTON KY
41094-8731
US

V. Phone/Fax

Practice location:
  • Phone: 954-399-4673
  • Fax: 513-636-7182
Mailing address:
  • Phone: 919-818-3377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number35.069810
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number50102
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: