Basic Information
| Provider Information | |||||||||
| NPI: | 1376568204 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANDERBURG | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | JASON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6015 CHENONCEAU BLVD STE 140 | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722234584 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5018688410 | ||||||||
| FaxNumber: | 5018688488 | ||||||||
| Practice Location | |||||||||
| Address1: | 6015 CHENONCEAU BLVD STE 140 | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722234584 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5018688410 | ||||||||
| FaxNumber: | 5018688488 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2006 | ||||||||
| LastUpdateDate: | 12/29/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | E4348 | AR | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 162281001 | 05 | AR | MEDICAID |