1548203524 NPI number — SHARON K VANDE VEGTE DO

Table of content: SHARON K VANDE VEGTE DO (NPI 1548203524)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548203524 NPI number — SHARON K VANDE VEGTE DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VANDE VEGTE
Provider First Name:
SHARON
Provider Middle Name:
K
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1548203524
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/02/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
700 E 2ND ST
Provider Second Line Business Mailing Address:
SUITE 2
Provider Business Mailing Address City Name:
IDA GROVE
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
51445-1601
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
712-364-2514
Provider Business Mailing Address Fax Number:
712-364-4430

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
700 E 2ND ST
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
IDA GROVE
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
51445-1601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
712-364-2514
Provider Business Practice Location Address Fax Number:
712-364-4430
Provider Enumeration Date:
06/14/2006

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: 207Q00000X , with the licence number:  03092 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207Q00000X , with the licence number: 427 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 2139709 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 42128384914 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 56248 . This is a "WELLMARK OF IA" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 49594 . This is a "WELLMARK" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 7701450 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1139709 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7701452 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".




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