Provider Demographics
NPI:1467406322
Name:VANDER ZWAAG, KRISTOFER A (MD)
Entity Type:Individual
Prefix:
First Name:KRISTOFER
Middle Name:A
Last Name:VANDER ZWAAG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:715 N SAINT JOSEPH AVE
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:NE
Mailing Address - Zip Code:68901-4451
Mailing Address - Country:US
Mailing Address - Phone:402-461-5191
Mailing Address - Fax:402-461-5088
Practice Address - Street 1:715 N SAINT JOSEPH AVE
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:NE
Practice Address - Zip Code:68901-4451
Practice Address - Country:US
Practice Address - Phone:402-463-0404
Practice Address - Fax:402-461-5088
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE228152085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE00059OtherBLUE CROSS BLUE SHIELD
KS106553OtherBLUE CROSS BLUE SHIELD
P00410877OtherRAILROAD MEDICARE
NE251187OtherMIDLANDS CHOICE
NE68901B014OtherTRICARE/TRIWEST
NE68901B014OtherTRICARE/TRIWEST
NEBV8727313OtherDEA
NE251187OtherMIDLANDS CHOICE