Provider Demographics
NPI:1356452106
Name:VANDER HORCK, MARK PHILLIP (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:PHILLIP
Last Name:VANDER HORCK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1130 LAKE PLAZA DR
Mailing Address - Street 2:SUITE #230
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906
Mailing Address - Country:US
Mailing Address - Phone:719-219-3819
Mailing Address - Fax:719-219-0411
Practice Address - Street 1:1130 LAKE PLAZA DR
Practice Address - Street 2:SUITE #230
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906
Practice Address - Country:US
Practice Address - Phone:719-219-3819
Practice Address - Fax:719-219-0411
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2009-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1049152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO08010496Medicaid
CO08010496Medicaid