Provider Demographics
NPI:1023205051
Name:VANDENBOSCH, MICHELLE H (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:H
Last Name:VANDENBOSCH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 WEDGEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-1503
Mailing Address - Country:US
Mailing Address - Phone:850-398-5408
Mailing Address - Fax:850-398-5408
Practice Address - Street 1:5808B HIGHWAY 189 N
Practice Address - Street 2:
Practice Address - City:BAKER
Practice Address - State:FL
Practice Address - Zip Code:32531-2506
Practice Address - Country:US
Practice Address - Phone:850-669-9023
Practice Address - Fax:850-669-9024
Is Sole Proprietor?:No
Enumeration Date:2007-10-03
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME82296207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL03170OtherBCBS
FL261831100Medicaid
FLK0872Medicare PIN