Provider Demographics
NPI:1437338407
Name:VANDUSEN, BRIAN E (OD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:E
Last Name:VANDUSEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:34590 COUNTY LINE RD
Mailing Address - Street 2:STE 1
Mailing Address - City:YUCAIPA
Mailing Address - State:CA
Mailing Address - Zip Code:92399-5303
Mailing Address - Country:US
Mailing Address - Phone:909-795-2416
Mailing Address - Fax:909-795-0477
Practice Address - Street 1:3559 W RAMSEY ST
Practice Address - Street 2:STE D-6
Practice Address - City:BANNING
Practice Address - State:CA
Practice Address - Zip Code:92220
Practice Address - Country:US
Practice Address - Phone:951-849-2020
Practice Address - Fax:951-849-4869
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-26
Last Update Date:2018-05-15
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CA007596T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0075960Medicaid
CASD0075961Medicaid
CASD0075961Medicaid