Healthcare Provider Details

I. General information

NPI: 1790733475
Provider Name (Legal Business Name): CAROLYN JILL VANDIVER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 03/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1750 NORTH HAMPTON ROAD
DESOTO TX
75115-2306
US

IV. Provider business mailing address

1750 NORTH HAMPTON ROAD
DESOTO TX
75115-2306
US

V. Phone/Fax

Practice location:
  • Phone: 214-946-4397
  • Fax: 214-946-4399
Mailing address:
  • Phone: 214-946-4397
  • Fax: 214-946-4399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberK8548
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: