Healthcare Provider Details

I. General information

NPI: 1487745139
Provider Name (Legal Business Name): JON VANDEVENTER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 SOUTH LANCASTER RD DALLAS VA - 128
DALLAS TX
75216
US

IV. Provider business mailing address

4500 SOUTH LANCASTER ROAD DALLAS VA - 128
DALLAS TX
75216
US

V. Phone/Fax

Practice location:
  • Phone: 214-857-1757
  • Fax:
Mailing address:
  • Phone: 214-857-1757
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P0004X
TaxonomySpinal Cord Injury Medicine Physician
License NumberG7958
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: