Provider Demographics
NPI:1982602157
Name:VANDONGEN, PHILIP CLARK (MD)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:CLARK
Last Name:VANDONGEN
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 1:148 GOV EDEN HOUSE RD
Mailing Address - Street 2:
Mailing Address - City:MERRY HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27957-9444
Mailing Address - Country:US
Mailing Address - Phone:304-839-7790
Mailing Address - Fax:
Practice Address - Street 1:211 VIRGINIA RD
Practice Address - Street 2:
Practice Address - City:EDENTON
Practice Address - State:NC
Practice Address - Zip Code:27932-9668
Practice Address - Country:US
Practice Address - Phone:252-482-8451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV19090207P00000X, 207R00000X
NC2012-01986207P00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA58-0474-4Medicaid
WV0080977000Medicaid
WV0080977000Medicaid
VA58-0474-4Medicaid