Provider Demographics
NPI:1013187855
Name:VORDERBRUGGEN, JOHN PETER (OPTICIAN)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:PETER
Last Name:VORDERBRUGGEN
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 N 23RD AVE W
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55806-1244
Mailing Address - Country:US
Mailing Address - Phone:218-726-0078
Mailing Address - Fax:
Practice Address - Street 1:901 N 23RD AVE W
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55806-1244
Practice Address - Country:US
Practice Address - Phone:218-726-0078
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-07
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2729202156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2100074OtherALLINA MEDICA