Basic Information
| Provider Information | |||||||||
| NPI: | 1790733475 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANDIVER | ||||||||
| FirstName: | CAROLYN | ||||||||
| MiddleName: | JILL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1750 NORTH HAMPTON ROAD | ||||||||
| Address2: | |||||||||
| City: | DESOTO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 751152306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2149464397 | ||||||||
| FaxNumber: | 2149464399 | ||||||||
| Practice Location | |||||||||
| Address1: | 1750 NORTH HAMPTON ROAD | ||||||||
| Address2: | |||||||||
| City: | DESOTO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 751152306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2149464397 | ||||||||
| FaxNumber: | 2149464399 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2006 | ||||||||
| LastUpdateDate: | 03/11/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | K8548 | TX | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 104934803 | 05 | TX | MEDICAID |