Provider Demographics
NPI:1225040249
Name:VANDERFELTZ, DONALD J (O D)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:J
Last Name:VANDERFELTZ
Suffix:
Gender:M
Credentials:O D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 E NORTH ST
Mailing Address - Street 2:P. O. BOX 246
Mailing Address - City:CALIFORNIA
Mailing Address - State:MO
Mailing Address - Zip Code:65018-1583
Mailing Address - Country:US
Mailing Address - Phone:573-796-2222
Mailing Address - Fax:573-796-4184
Practice Address - Street 1:202 E NORTH ST
Practice Address - Street 2:
Practice Address - City:CALIFORNIA
Practice Address - State:MO
Practice Address - Zip Code:65018-1583
Practice Address - Country:US
Practice Address - Phone:573-796-2222
Practice Address - Fax:573-796-4184
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT02337152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO123785OtherHEALTHLINK
MO22-00862OtherUNITED HEALTHCARE
MO310208921Medicaid
MO109091OtherBLUE CROSS BLUE SHIELD
MOT42545OtherMERCY HEALTH
MO310208921Medicaid
MO22-00862OtherUNITED HEALTHCARE
MOT42545OtherMERCY HEALTH