Provider Demographics
NPI:1194752055
Name:VANDEMARK, MELANIE RENEE (MD)
Entity type:Individual
Prefix:DR
First Name:MELANIE
Middle Name:RENEE
Last Name:VANDEMARK
Suffix:
Gender:F
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:PO BOX 741240
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32774-1240
Mailing Address - Country:US
Mailing Address - Phone:386-740-1701
Mailing Address - Fax:
Practice Address - Street 1:1450 S WOODLAND BLVD
Practice Address - Street 2:SUITE 300-C
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-7767
Practice Address - Country:US
Practice Address - Phone:386-740-1701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME91200207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLI21452Medicare UPIN
FL52043BMedicare ID - Type Unspecified