Provider Demographics
NPI:1861759862
Name:VANDEVAR, MARJAN (DO)
Entity type:Individual
Prefix:DR
First Name:MARJAN
Middle Name:
Last Name:VANDEVAR
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 SE 13TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33316-1923
Mailing Address - Country:US
Mailing Address - Phone:305-479-4638
Mailing Address - Fax:
Practice Address - Street 1:315 SE 13TH ST
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-1923
Practice Address - Country:US
Practice Address - Phone:954-767-5900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-13
Last Update Date:2021-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLUO2056207R00000X
FLOS12532207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010750300Medicaid
FL010750300Medicaid