Provider Demographics
NPI:1528138534
Name:VANDERBILT, DOUGLAS L (MD)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:L
Last Name:VANDERBILT
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:PO BOX 23371
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37422-3371
Mailing Address - Country:US
Mailing Address - Phone:423-892-9208
Mailing Address - Fax:423-892-9212
Practice Address - Street 1:721 GLENWOOD DRIVE
Practice Address - Street 2:MEMORIAL BLDG., WEST SUITE 470
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37404-1126
Practice Address - Country:US
Practice Address - Phone:423-892-9208
Practice Address - Fax:423-892-9212
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2009-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7995208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3184016Medicaid
3384417Medicare PIN
TN3184016Medicaid
TN3384417Medicare ID - Type Unspecified