Basic Information
| Provider Information | |||||||||
| NPI: | 1194728428 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VARDIMAN | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2929 CALDER ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | BEAUMONT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 777021845 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4098339797 | ||||||||
| FaxNumber: | 4098393174 | ||||||||
| Practice Location | |||||||||
| Address1: | 2010 DOWLEN RD | ||||||||
| Address2: | |||||||||
| City: | BEAUMONT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 777062525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4098339797 | ||||||||
| FaxNumber: | 4098393174 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2005 | ||||||||
| LastUpdateDate: | 05/08/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | D1093 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 116938504 | 05 | TX | MEDICAID |