Basic Information
| Provider Information | |||||||||
| NPI: | 1164809489 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANDERMOLEN | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 936857 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 311936857 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106629500 | ||||||||
| FaxNumber: | 9106629501 | ||||||||
| Practice Location | |||||||||
| Address1: | 1415 PHYSICIANS DR | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284017338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106629500 | ||||||||
| FaxNumber: | 9106629501 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2015 | ||||||||
| LastUpdateDate: | 02/07/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 2018-01727 | NC | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 2018-01727 | NC | N | Allopathic & Osteopathic Physicians | Hospitalist | 390200000X | 209834 | NC | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207RC0000X | 2018-01727 | NC | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.