1437338407 NPI number — DR. BRIAN E VANDUSEN O.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437338407 NPI number — DR. BRIAN E VANDUSEN O.D.

Organization/Personal Information

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

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:
1437338407
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/15/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
34590 COUNTY LINE RD
Provider Second Line Business Mailing Address:
STE 1
Provider Business Mailing Address City Name:
YUCAIPA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92399-5303
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-795-2416
Provider Business Mailing Address Fax Number:
909-795-0477

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3559 W RAMSEY ST
Provider Second Line Business Practice Location Address:
STE D-6
Provider Business Practice Location Address City Name:
BANNING
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92220
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-849-2020
Provider Business Practice Location Address Fax Number:
951-849-4869
Provider Enumeration Date:
10/26/2007

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:  007596T , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: SD0075960 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: SD0075961 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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