Provider Demographics
NPI:1053429456
Name:EBERLY, VANCE CHARLES (MD)
Entity type:Individual
Prefix:DR
First Name:VANCE
Middle Name:CHARLES
Last Name:EBERLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:11525 BROOKSHIRE AVE
Mailing Address - Street 2:SUITE #405
Mailing Address - City:DOWNEY
Mailing Address - State:CA
Mailing Address - Zip Code:90241-4985
Mailing Address - Country:US
Mailing Address - Phone:562-923-6112
Mailing Address - Fax:562-923-6181
Practice Address - Street 1:11525 BROOKSHIRE AVE
Practice Address - Street 2:SUITE #405
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90241-4985
Practice Address - Country:US
Practice Address - Phone:562-923-6112
Practice Address - Fax:562-923-6181
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-26
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG81586207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
G85042Medicare UPIN
G79362Medicare ID - Type Unspecified