Provider Demographics
NPI:1285324061
Name:VANDERBILT, JAMES
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:VANDERBILT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 W BROADWAY UNIT 1896
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92815-2088
Mailing Address - Country:US
Mailing Address - Phone:171-436-9472
Mailing Address - Fax:
Practice Address - Street 1:11153 LUKE ST
Practice Address - Street 2:
Practice Address - City:FORT BLISS
Practice Address - State:TX
Practice Address - Zip Code:79918-8010
Practice Address - Country:US
Practice Address - Phone:714-369-4727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-15
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA723689163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical