Provider Demographics
NPI:1477679231
Name:VANAMERONGEN, KENNETH (OD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:VANAMERONGEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1209 W EISENHOWER BLVD
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80537-3128
Mailing Address - Country:US
Mailing Address - Phone:970-667-3445
Mailing Address - Fax:970-667-8426
Practice Address - Street 1:1209 W EISENHOWER BLVD
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80537-3128
Practice Address - Country:US
Practice Address - Phone:970-667-3445
Practice Address - Fax:970-667-8426
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2008-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1449152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO5304510001Medicare NSC
COC42123Medicare PIN