Provider Demographics
NPI:1245430370
Name:VANDEBERG, BECKY LEE MCILONIE (OD)
Entity Type:Individual
Prefix:DR
First Name:BECKY
Middle Name:LEE MCILONIE
Last Name:VANDEBERG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:BECKY
Other - Middle Name:LEE
Other - Last Name:MCILONIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:400 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-1951
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1702 UNIVERSITY DR S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-4940
Practice Address - Country:US
Practice Address - Phone:701-364-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-18
Last Update Date:2020-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND652152W00000X
MN3090152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist