Provider Demographics
NPI:1053352740
Name:VANDERENDE, DANIEL SCOTT (MD DTM&H)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:SCOTT
Last Name:VANDERENDE
Suffix:
Gender:M
Credentials:MD DTM&H
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 OAKLAND ST
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-2431
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:408 OAKLAND ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-2431
Practice Address - Country:US
Practice Address - Phone:404-686-7869
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-10
Last Update Date:2012-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000032003207R00000X
GA58026207R00000X
SCTL28808207R00000X
VA0101239536207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNH42522Medicare UPIN