Healthcare Provider Details

I. General information

NPI: 1982602157
Provider Name (Legal Business Name): PHILIP CLARK VANDONGEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 06/03/2021
Certification Date: 06/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 VIRGINIA RD
EDENTON NC
27932-9668
US

IV. Provider business mailing address

148 GOV EDEN HOUSE RD
MERRY HILL NC
27957-9444
US

V. Phone/Fax

Practice location:
  • Phone: 252-482-8451
  • Fax:
Mailing address:
  • Phone: 304-839-7790
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number19090
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2012-01986
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number19090
License Number StateWV
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2012-01986
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: