Provider Demographics
NPI:1407802713
Name:VANDENBOSCH, MICHAEL ERIC (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ERIC
Last Name:VANDENBOSCH
Suffix:
Gender:M
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:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:605-328-9200
Mailing Address - Fax:605-328-6201
Practice Address - Street 1:1621 S MINNESOTA AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-1743
Practice Address - Country:US
Practice Address - Phone:605-328-9200
Practice Address - Fax:605-328-9201
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA27646207W00000X
SD5762207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
E73716Medicare UPIN
SDS100969Medicare PIN