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General NPI Number Information
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NPI Number | 1699978304
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Entity Type | Organization
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Legal Business Name | THEODORE VANDAM M.D.
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Dates
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Enumeration Date | 06/08/2007
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Last Update Date | 07/28/2010
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Provider Practice Location Address
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Address Line | 665 CAMINO DE LOS MARES STE 210
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City | SAN CLEMENTE
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State | CA
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Zip | 92673-2859
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Country | US
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Telephone | 949-240-6772
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Fax | 949-240-6841
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Provider Business Mailing Address
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Address Line | 665 CAMINO DE LOS MARES STE 210
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City | SAN CLEMENTE
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State | CA
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Zip | 92673-2859
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Country | US
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Telephone | 949-240-6772
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Fax | 949-240-6841
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Authorized Official
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Title or Position | PRESIDENT
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Name | THEODORE VANDAM
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Credential | M.D.
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Telephone | 949-240-6772
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | A24788
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License Number State | CA
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