Provider Demographics
NPI:1386660223
Name:VANDEWEGHE, CHRISTINE I (OD)
Entity Type:Individual
Prefix:MS
First Name:CHRISTINE
Middle Name:I
Last Name:VANDEWEGHE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:MS
Other - First Name:CHRISTINE
Other - Middle Name:I
Other - Last Name:RUPP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:1125 S BEACON
Practice Address - Street 2:
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-2651
Practice Address - Country:US
Practice Address - Phone:616-846-4454
Practice Address - Fax:269-342-4284
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003713152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U54124Medicare UPIN
MI0733500016Medicare NSC
MI0C97655024Medicare PIN