Provider Demographics
NPI:1003852849
Name:VANDENBURGH, CORTNEY A (DO)
Entity Type:Individual
Prefix:MRS
First Name:CORTNEY
Middle Name:A
Last Name:VANDENBURGH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:CORTNEY
Other - Middle Name:ANN
Other - Last Name:GILBERTSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-381-2222
Mailing Address - Fax:
Practice Address - Street 1:1450 AVIATION DR
Practice Address - Street 2:SUITE 100
Practice Address - City:HAILEY
Practice Address - State:ID
Practice Address - Zip Code:83333-8785
Practice Address - Country:US
Practice Address - Phone:208-788-3434
Practice Address - Fax:208-788-2025
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2014-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO0419207Q00000X
IDMR0827207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807191900Medicaid
IDP00721168OtherMCRR
RES000Medicare UPIN
ID807191900Medicaid
ID20001827Medicare PIN