Healthcare Provider Details

I. General information

NPI: 1295870459
Provider Name (Legal Business Name): SOUTHWESTERN DIABETIC PHYSICIANS ASSOCIATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10687 FM 678
WHITESBORO TX
76273-4840
US

IV. Provider business mailing address

PO BOX 918
GAINESVILLE TX
76241-0918
US

V. Phone/Fax

Practice location:
  • Phone: 940-665-2011
  • Fax: 940-665-9467
Mailing address:
  • Phone: 940-665-2011
  • Fax: 940-665-9467

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License NumberG8080
License Number StateTX

VIII. Authorized Official

Name: DR. ROBERT D VANDERMEER
Title or Position: PRESIDENT
Credential: M.D.
Phone: 940-665-2011