MEDICARE: DR. SHAWN DAVID VANDEMARK M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208200000X	Plastic Surgery Physician	057510	GA

General Provider Information

NPI Number	:	1336188176
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SHAWN DAVID VANDEMARK M.D.

Provider Business Mailing Address
First Line	:	PO BOX 0070
Second Line	:
City	:	VALDOSTA
State	:	GA
Zip	:	31603-0070
Country	:	US
Telephone Number	:	229-333-1711
Fax Number	:	229-333-1719

Provider Business Practice Location Address
First Line	:	2409 N PATTERSON ST STE 200
Second Line	:
City	:	VALDOSTA
State	:	GA
Zip	:	31602-2512
Country	:	US
Telephone Number	:	229-333-1711
Fax Number	:	229-333-1719

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/06/2006
Last Update Date	:	03/26/2018

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