Basic Information
| Provider Information | |||||||||
| NPI: | 1750356762 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANDIVER | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | F. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1310 | ||||||||
| Address2: | |||||||||
| City: | TRUSSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 351736102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2056612080 | ||||||||
| FaxNumber: | 2056612085 | ||||||||
| Practice Location | |||||||||
| Address1: | 4929 UNIVERSITY DR NW | ||||||||
| Address2: | SUITE F | ||||||||
| City: | HUNTSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 358161862 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2569642020 | ||||||||
| FaxNumber: | 2568305239 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2006 | ||||||||
| LastUpdateDate: | 09/21/2010 | ||||||||
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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 | 152W00000X | S-A86-TA-680 | AL | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 051528869 | 05 | AL | MEDICAID | MV1275672 | 01 | AL | DEA | OTHER | 009932978 | 05 | AL | MEDICAID | 116545 | 05 | AL | MEDICAID | S-A86-TA-680 | 01 | AL | AL BOARD OF OPTOMETRY | OTHER |