Provider Demographics
NPI:1235120544
Name:VANDERBOSCH, CYNTHIA L (MD)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:L
Last Name:VANDERBOSCH
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 1:3534 BROOKLYN AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46809-1361
Mailing Address - Country:US
Mailing Address - Phone:260-747-6171
Mailing Address - Fax:260-478-5125
Practice Address - Street 1:2516 E DUPONT RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1608
Practice Address - Country:US
Practice Address - Phone:260-471-7622
Practice Address - Fax:260-489-5469
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01037767A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN080122015OtherRAILROAD MEDICARE
IN100369350Medicaid
000000091894OtherBLUE CROSS BLUE SHIELD
000000000312OtherMPLAN
1975OtherPHYSICIANS HEALTH PLAN
000000091894OtherBLUE CROSS BLUE SHIELD
INM400048192Medicare PIN
IN080122015OtherRAILROAD MEDICARE
1975OtherPHYSICIANS HEALTH PLAN
E11160Medicare UPIN