Provider Demographics
NPI:1689890949
Name:VANDENBERG, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:VANDENBERG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 NE 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33305-3171
Mailing Address - Country:US
Mailing Address - Phone:920-850-5758
Mailing Address - Fax:
Practice Address - Street 1:1601 NE 11TH AVE
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33305-3171
Practice Address - Country:US
Practice Address - Phone:920-850-5758
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA20097174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist