Provider Demographics
NPI:1710091079
Name:VANDERLINDE, DAVID S (OD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:S
Last Name:VANDERLINDE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4470 N LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:BLACK RIVER
Mailing Address - State:MI
Mailing Address - Zip Code:48721-9775
Mailing Address - Country:US
Mailing Address - Phone:989-724-7902
Mailing Address - Fax:
Practice Address - Street 1:1180 M-32 WEST
Practice Address - Street 2:
Practice Address - City:ALPENA
Practice Address - State:MI
Practice Address - Zip Code:49707
Practice Address - Country:US
Practice Address - Phone:989-354-7431
Practice Address - Fax:989-354-7532
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002833152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOM-96380Medicare PIN
MIU37896Medicare UPIN