Provider Demographics
NPI:1598857005
Name:VANDERHEIDEN, TERENCE LYNN (DPM)
Entity Type:Individual
Prefix:
First Name:TERENCE
Middle Name:LYNN
Last Name:VANDERHEIDEN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 30TH AVE W
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:MN
Mailing Address - Zip Code:56308-3426
Mailing Address - Country:US
Mailing Address - Phone:320-763-2540
Mailing Address - Fax:320-763-5749
Practice Address - Street 1:610 30TH AVE W
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-3426
Practice Address - Country:US
Practice Address - Phone:320-763-2540
Practice Address - Fax:320-763-5749
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2219213E00000X
MN808213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E46150Medicaid
MN1598857005Medicaid
CA454788OtherINTERPLAN
CA000810816204OtherPHCS
MN1598857005OtherBLUE CROSS BLUE SHIELD
CA2481192OtherUNITED HEALTHCARE
CA0309120OtherCIGNA
CAE4615OtherBLUE CROSS
CA5716593OtherFIRST HEALTH
MN0027-0001472OtherMEDICA
CA90197471OtherPACIFICARE
CAMCMG488100OtherWESTERN HEALTH ADVANTAGE
CA110834OtherHEALTH NET
CA1904853OtherGREAT WEST
CA7637749OtherAETNA
MN6697670002Medicare NSC
CA000E46150Medicaid
CA2481192OtherUNITED HEALTHCARE
CA000E46151Medicare ID - Type Unspecified