Provider Demographics
NPI:1326142811
Name:VANDERHOOF, MICHAEL (OPTICIAN05/23/1946)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:VANDERHOOF
Suffix:
Gender:M
Credentials:OPTICIAN05/23/1946
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:608 COLLEGE HWY
Mailing Address - Street 2:
Mailing Address - City:SOUTHWICK
Mailing Address - State:MA
Mailing Address - Zip Code:01077-9579
Mailing Address - Country:US
Mailing Address - Phone:413-569-6446
Mailing Address - Fax:413-569-0890
Practice Address - Street 1:608 COLLEGE HWY
Practice Address - Street 2:
Practice Address - City:SOUTHWICK
Practice Address - State:MA
Practice Address - Zip Code:01077-9579
Practice Address - Country:US
Practice Address - Phone:413-569-6446
Practice Address - Fax:413-569-0890
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1951156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1519816Medicaid
MA0424310001Medicare ID - Type Unspecified