Provider Demographics
NPI:1548203524
Name:VANDE VEGTE, SHARON K (DO)
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:K
Last Name:VANDE VEGTE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 E 2ND ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:IDA GROVE
Mailing Address - State:IA
Mailing Address - Zip Code:51445-1601
Mailing Address - Country:US
Mailing Address - Phone:712-364-2514
Mailing Address - Fax:712-364-4430
Practice Address - Street 1:700 E 2ND ST
Practice Address - Street 2:SUITE 2
Practice Address - City:IDA GROVE
Practice Address - State:IA
Practice Address - Zip Code:51445-1601
Practice Address - Country:US
Practice Address - Phone:712-364-2514
Practice Address - Fax:712-364-4430
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA03092207Q00000X
NE427207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA2139709Medicaid
IA42128384914Medicaid
IA56248OtherWELLMARK OF IA
IA49594OtherWELLMARK
IA7701450Medicaid
IA1139709Medicaid
SD7701452Medicaid
IAG34005Medicare UPIN
IA42128384914Medicaid
IA7701450Medicaid
IA1139709Medicaid