Provider Demographics
NPI:1205861291
Name:VANDERVORT, ROBERT STEPHEN (OD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:STEPHEN
Last Name:VANDERVORT
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 1:9900 NICHOLAS ST STE 250
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68114-2261
Mailing Address - Country:US
Mailing Address - Phone:402-493-6500
Mailing Address - Fax:402-493-4370
Practice Address - Street 1:9900 NICHOLAS ST
Practice Address - Street 2:STE 275
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-2149
Practice Address - Country:US
Practice Address - Phone:402-493-6500
Practice Address - Fax:402-493-4370
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE926152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025382400Medicaid
IA2987990Medicaid
NE37118OtherBCBS
IA96854OtherBCBS
NE37191OtherBCBS
IA99846OtherBCBS
NE10025541400Medicaid
IA71804OtherBCBS
NEP00327582OtherPALMETTO RAILROAD
IAIB1076002Medicare PIN
NE281629Medicare PIN
NE37191OtherBCBS
IA96854OtherBCBS