Provider Demographics
NPI:1124075718
Name:VANNEMAN, WILLIAM MOORE (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:MOORE
Last Name:VANNEMAN
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 1:91 MONTVALE AVE
Mailing Address - Street 2:
Mailing Address - City:STONEHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02180-3623
Mailing Address - Country:US
Mailing Address - Phone:781-864-1295
Mailing Address - Fax:
Practice Address - Street 1:955 MAIN ST
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:MA
Practice Address - Zip Code:01890-1961
Practice Address - Country:US
Practice Address - Phone:781-729-5855
Practice Address - Fax:781-721-5891
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA38046207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0160725Medicaid
MAC20230OtherBLUE CROSS & BLUE SHIELD
MA38046OtherTUFTS
MA24794OtherUS HEALTHCARE
MA30034OtherHARVARD PILGRIM
MA30034OtherHARVARD PILGRIM
MA0160725Medicaid