Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204C00000X | Sports Medicine Doctor | 038391 | GA |
NPI | 1740321579 |
---|---|
Provider Name | Dr. Brian Stephen Vanderhoof |
First Address | Snellville, GA 30078-2689 |
Second Address | Snellville, GA 30078-2689 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/02/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00665695A | (05) | GA |
G11669 | (02) | GA |