Provider Demographics
NPI:1245277573
Name:VANUDEN, ROBERT (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:
Last Name:VANUDEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 490
Mailing Address - Street 2:
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39649-0490
Mailing Address - Country:US
Mailing Address - Phone:601-249-4282
Mailing Address - Fax:601-249-4852
Practice Address - Street 1:1506 ASTON AVE
Practice Address - Street 2:
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648-2735
Practice Address - Country:US
Practice Address - Phone:601-249-4282
Practice Address - Fax:601-249-4852
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS11542207RS0010X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00095703Medicaid
MS200000453Medicare PIN