Provider Demographics
NPI:1447357736
Name:VANDERHEIDE, JOHN W (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:W
Last Name:VANDERHEIDE
Suffix:
Gender:M
Credentials:MD
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 62106
Mailing Address - Street 2:
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93160-2106
Mailing Address - Country:US
Mailing Address - Phone:805-681-1761
Mailing Address - Fax:805-681-1768
Practice Address - Street 1:215 PESETAS LN
Practice Address - Street 2:
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93110-1416
Practice Address - Country:US
Practice Address - Phone:806-681-1761
Practice Address - Fax:805-681-1768
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2011-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG32295207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G322950Medicaid
CA00G322950Medicaid
CAWG32295AMedicare PIN