Provider Demographics
NPI:1689655789
Name:VANDER POL, ANTOINETTE J (MD)
Entity Type:Individual
Prefix:
First Name:ANTOINETTE
Middle Name:J
Last Name:VANDER POL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 W GLYNN DR
Mailing Address - Street 2:
Mailing Address - City:PARKSTON
Mailing Address - State:SD
Mailing Address - Zip Code:57366-9605
Mailing Address - Country:US
Mailing Address - Phone:605-928-3311
Mailing Address - Fax:605-928-7368
Practice Address - Street 1:401 W GLYNN DR
Practice Address - Street 2:
Practice Address - City:PARKSTON
Practice Address - State:SD
Practice Address - Zip Code:57366-9605
Practice Address - Country:US
Practice Address - Phone:605-928-3311
Practice Address - Fax:605-928-7368
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD4723207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9169682OtherDAKOTACARE
SD0007357OtherWELLMARK PARKSTON
SD4997645OtherWELLMARK - LAKE ANDES
SD5610842Medicaid
H18742Medicare UPIN
SD080161311Medicare PIN
SD080161264Medicare PIN
SDS7357Medicare PIN
SDS7362Medicare PIN