Healthcare Provider Details

I. General information

NPI: 1699351338
Provider Name (Legal Business Name): JONATHAN DANIEL VANDENBERG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2021
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 BLYTHE BLVD
CHARLOTTE NC
28203-5812
US

IV. Provider business mailing address

1000 BLYTHE BLVD
CHARLOTTE NC
28203-5812
US

V. Phone/Fax

Practice location:
  • Phone: 704-355-2000
  • Fax:
Mailing address:
  • Phone: 704-355-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2026-03583
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberTRN33392
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: