Provider Demographics
NPI:1851681415
Name:VANDAM, RICHARD J (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:J
Last Name:VANDAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:RICHARD
Other - Middle Name:JACOB
Other - Last Name:VANDAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1266 HIGHWAY 515
Mailing Address - Street 2:PIEDMONT MOUNTAINSIDE HOSPITAL
Mailing Address - City:JASPER
Mailing Address - State:GA
Mailing Address - Zip Code:30143
Mailing Address - Country:US
Mailing Address - Phone:404-977-8043
Mailing Address - Fax:
Practice Address - Street 1:1266 HIGHWAY 515
Practice Address - Street 2:PIEDMONT MOUNTAINSIDE HOSPITAL
Practice Address - City:JASPER
Practice Address - State:GA
Practice Address - Zip Code:30143
Practice Address - Country:US
Practice Address - Phone:404-977-8043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-15
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA071296207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine