Provider Demographics
NPI:1124064407
Name:VANDRAKE, VANCE V (MD)
Entity type:Individual
Prefix:
First Name:VANCE
Middle Name:V
Last Name:VANDRAKE
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 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11104 PARKVIEW CIRCLE DR
Practice Address - Street 2:SUITE 310
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1672
Practice Address - Country:US
Practice Address - Phone:260-266-5230
Practice Address - Fax:260-266-5238
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01030783207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0511995Medicaid
IN100355760Medicaid
IN925060AAAMedicare PIN
OH0511995Medicaid