Provider Demographics
NPI:1558397109
Name:VANDENBERG, HERBERT F (MD)
Entity Type:Individual
Prefix:
First Name:HERBERT
Middle Name:F
Last Name:VANDENBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:862 SPRING CREEK RD
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-7506
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:615 S TRENTON ST
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-5040
Practice Address - Country:US
Practice Address - Phone:318-251-2322
Practice Address - Fax:318-251-0710
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11649R2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1681032Medicaid
LAF85704Medicare UPIN
LA1681032Medicaid