Basic Information
| Provider Information | |||||||||
| NPI: | 1700885563 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VANDRUFF | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3815 E BELL RD STE 2200 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850322139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6026333838 | ||||||||
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| Practice Location | |||||||||
| Address1: | 111 W CEDAR LN | ||||||||
| Address2: | SUITE A | ||||||||
| City: | PAYSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 855415417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9284724675 | ||||||||
| FaxNumber: | 9284723431 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2005 | ||||||||
| LastUpdateDate: | 05/11/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 15630 | AZ | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 271122 | 05 | AZ | MEDICAID | AZ0850760 | 01 | AZ | BCBS | OTHER |