Provider Demographics
NPI:1629344189
Name:VANDENBOOM, TIMOTHY GERARD II (MD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:GERARD
Last Name:VANDENBOOM
Suffix:II
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 1:24 FRANK LLOYD WRIGHT DR LBBY J2000
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-9484
Mailing Address - Country:US
Mailing Address - Phone:734-747-6766
Mailing Address - Fax:
Practice Address - Street 1:5301 E HURON RIVER DR
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-1051
Practice Address - Country:US
Practice Address - Phone:734-712-3161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-29
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125062313207ZP0102X
MI4301114577207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology