Provider Demographics
NPI:1528222387
Name:VANDERHEYDEN, THOMAS R JR (DO)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:R
Last Name:VANDERHEYDEN
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17501 GENERATIONS DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46635-1589
Mailing Address - Country:US
Mailing Address - Phone:574-234-0049
Mailing Address - Fax:
Practice Address - Street 1:17501 GENERATIONS DR
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46635-1589
Practice Address - Country:US
Practice Address - Phone:574-234-0049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-10
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125-050866207R00000X
IN02004009A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000777772OtherANTHEM
IN201066120Medicaid
INM400074474Medicare PIN