Provider Demographics
NPI:1568408268
Name:VANDERKLEED, ROBERT M (OD (DOCTOR OF OPTO)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:M
Last Name:VANDERKLEED
Suffix:
Gender:M
Credentials:OD (DOCTOR OF OPTO
Other - Prefix:DR
Other - First Name:ROBERT
Other - Middle Name:
Other - Last Name:VANDERKLEED
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:7210 S.ALGONQUIAN ST
Mailing Address - Street 2:#24-103
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80016
Mailing Address - Country:US
Mailing Address - Phone:206-841-5747
Mailing Address - Fax:
Practice Address - Street 1:7210 S.ALGONQUIAN ST
Practice Address - Street 2:#24-103
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80016
Practice Address - Country:US
Practice Address - Phone:206-841-5747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-21
Last Update Date:2013-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3025152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2069102Medicaid
WAG8860737Medicare PIN
T01879Medicare UPIN