Provider Demographics
NPI:1588642367
Name:VANDENBOSCH, DANIEL T (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:T
Last Name:VANDENBOSCH
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 1:2230 WILEY BLVD SW
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52404-2364
Mailing Address - Country:US
Mailing Address - Phone:319-396-1983
Mailing Address - Fax:319-396-3183
Practice Address - Street 1:2375 EDGEWOOD RD SW
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52404-4736
Practice Address - Country:US
Practice Address - Phone:319-396-1983
Practice Address - Fax:319-396-3183
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA29364207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA930029628OtherRR MEDICARE
IA7085159Medicaid
IA6085159Medicaid
IA930029628OtherRR MEDICARE
F58986Medicare UPIN