1013997147 NPI number — DR. AMY M DEJONG O.D.

Table of content: DR. AMY M DEJONG O.D. (NPI 1013997147)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013997147 NPI number — DR. AMY M DEJONG O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEJONG
Provider First Name:
AMY
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013997147
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/27/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
120 W MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VERMILLION
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57069-3036
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-624-4291
Provider Business Mailing Address Fax Number:
604-624-6822

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 W MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VERMILLION
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57069-3036
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-624-4291
Provider Business Practice Location Address Fax Number:
604-624-6822
Provider Enumeration Date:
01/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  578 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 152W00000X , with the licence number: 02198 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 238521 . This is a "MIDLANDS CHOICE, AETNA, CIGNA" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 399493 . This is a "COVENTRY HEALTH CARE OF IOWA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4995791 . This is a "BLUE SHIELD PROVIDER" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 32866 . This is a "SANFORD HEALTH PLAN" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 9219420 . This is a "DAKOTACARE GROUP NUMBER" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 11321 . This is a "AVERA HEALTH PLANS" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 200648368 . This is a "TRICARE/TRIWEST PROVIDER" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 578 . This is a "DAKOTACARE PIN" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: OP2175 . This is a "EYEMED" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 578 . This is a "DAKOTACARE PROVIDER NUMBE" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 2203601 . This is a "MEDICA UNITEDHEALTHCARE" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 6056244291 . This is a "VISION SERVICE PLAN" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: I3186 . This is a "SANFORD PIN" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 9200863 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".




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