Provider Demographics
NPI:1447290630
Name:VANDE WAA, JOHN A (DO, PHD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:VANDE WAA
Suffix:
Gender:M
Credentials:DO, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 40480
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36640-0480
Mailing Address - Country:US
Mailing Address - Phone:251-470-5890
Mailing Address - Fax:251-471-7925
Practice Address - Street 1:2451 FILLINGIM ST
Practice Address - Street 2:MASTIN BLDG
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36617-2238
Practice Address - Country:US
Practice Address - Phone:251-470-5890
Practice Address - Fax:251-471-7925
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALDO-401207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00121697Medicaid
AL009935162Medicaid
FL255961700Medicaid
AL92-10077OtherUNITED HEALTHCARE
AL51505303OtherBCBS
AL51532424OtherBCBS
AL000023305Medicaid
AL009975140Medicaid
FL1503762Medicaid
AL51023305OtherBCBS
AL51543343OtherBCBS - FILLINGIM ST
FL255961700Medicaid
AL009975140Medicaid
FL255961700Medicaid