Provider Demographics
NPI:1154384022
Name:VANCE, DONALD ALTON (MD)
Entity type:Individual
Prefix:DR
First Name:DONALD
Middle Name:ALTON
Last Name:VANCE
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 1:4201 SWEETWATER RD
Mailing Address - Street 2:
Mailing Address - City:BONITA
Mailing Address - State:CA
Mailing Address - Zip Code:91902-1415
Mailing Address - Country:US
Mailing Address - Phone:619-479-9325
Mailing Address - Fax:619-479-6262
Practice Address - Street 1:4201 SWEETWATER RD
Practice Address - Street 2:
Practice Address - City:BONITA
Practice Address - State:CA
Practice Address - Zip Code:91902-1415
Practice Address - Country:US
Practice Address - Phone:619-479-9325
Practice Address - Fax:619-479-6262
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-10
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC0034997207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A35798Medicare UPIN
CAWC34997CMedicare ID - Type Unspecified