Provider Demographics
NPI:1033733852
Name:VANDERGULIK, IAN (DPM)
Entity Type:Individual
Prefix:DR
First Name:IAN
Middle Name:
Last Name:VANDERGULIK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 SPURS LN STE 300
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78240-1679
Mailing Address - Country:US
Mailing Address - Phone:860-770-5113
Mailing Address - Fax:
Practice Address - Street 1:21 SPURS LN STE 300
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78240-1679
Practice Address - Country:US
Practice Address - Phone:210-699-8326
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-08
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX692084213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery