Provider Demographics
NPI:1073951612
Name:VOGELPOHL, DEREK PAUL (OD)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:PAUL
Last Name:VOGELPOHL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 AVENUE H STE 2
Mailing Address - Street 2:
Mailing Address - City:FORT MADISON
Mailing Address - State:IA
Mailing Address - Zip Code:52627-4559
Mailing Address - Country:US
Mailing Address - Phone:319-316-6016
Mailing Address - Fax:319-669-8335
Practice Address - Street 1:1001 AVENUE H STE 2
Practice Address - Street 2:
Practice Address - City:FORT MADISON
Practice Address - State:IA
Practice Address - Zip Code:52627-4559
Practice Address - Country:US
Practice Address - Phone:319-316-6016
Practice Address - Fax:319-669-8335
Is Sole Proprietor?:No
Enumeration Date:2013-06-05
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046010660152W00000X
IA002587152W00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1073951612Medicaid
IL1073951612Medicaid
IA1073951612Medicaid