John R. Vydareny, MD

Primary specialty

Dermatology PhysicianTaxonomy code 207N00000X

License

JV028722 Issued in MI

Practice address

833 Michigan St NE
Suite 102
Grand Rapids, MI 49503-3523

Phone

(616) 459-1144

Fax

(616) 459-0313

NPI assigned

Nov 8, 2005

Last updated

Mar 16, 2015By the provider in NPPES

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• John R Vydareny MD PC

  • Dermatology Physician
  • Grand Rapids, MI
  • NPI 1255502605
  Authorized official Same address or phone

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1131408000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1426464000000",
    "number": "1619958576",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "833 MICHIGAN ST NE",
            "address_2": "SUITE 102",
            "city": "GRAND RAPIDS",
            "state": "MI",
            "postal_code": "495033523",
            "telephone_number": "616-459-1144",
            "fax_number": "616-459-0313"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "833 MICHIGAN ST NE",
            "address_2": "SUITE 102",
            "city": "GRAND RAPIDS",
            "state": "MI",
            "postal_code": "495033523",
            "telephone_number": "616-459-1144",
            "fax_number": "616-459-0313"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "VYDARENY",
        "first_name": "JOHN",
        "middle_name": "R.",
        "name_prefix": "Dr.",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2005-11-08",
        "last_updated": "2015-03-16",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "",
            "desc": "Dermatology",
            "state": "MI",
            "license": "JV028722",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1075285",
            "state": "MI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Dermatology Physician in Grand Rapids, MI
• Providers in Grand Rapids, MI by specialty
• Dermatology Physician in Michigan

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 16, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.