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General NPI Number Information
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NPI Number | 1780801407
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Entity Type | Individual
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Provider Name | PAUL M VANDIVORT JR. MD
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Gender | Male
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Dates
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Enumeration Date | 04/20/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 141 N MERAMEC AVE STE 306
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City | CLAYTON
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State | MO
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Zip | 63105-3750
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Country | US
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Telephone | 314-721-2286
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Fax |
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Provider Business Mailing Address
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Address Line | 141 N MERAMEC AVE STE 306
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City | CLAYTON
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State | MO
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Zip | 63105-3750
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Country | US
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Telephone | 314-721-2286
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | MD R8670
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License Number State | MO
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