Basic Information
| Provider Information | |||||||||
| NPI: | 1891291308 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANDERLOO | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | GABRIEL | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 415 S 28TH AVE | ||||||||
| Address2: | |||||||||
| City: | HATTIESBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394017246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6015795400 | ||||||||
| FaxNumber: | 6015795240 | ||||||||
| Practice Location | |||||||||
| Address1: | 4209 LINCOLN RD | ||||||||
| Address2: | |||||||||
| City: | HATTIESBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394023065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6015795400 | ||||||||
| FaxNumber: | 6015795240 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2018 | ||||||||
| LastUpdateDate: | 07/15/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 26911 | MS | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.