Provider Demographics
NPI:1750638516
Name:VANDENBERG, CHARLES JAY IV (DO)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:JAY
Last Name:VANDENBERG
Suffix:IV
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1391 E PARKDALE AVE
Mailing Address - Street 2:
Mailing Address - City:MANISTEE
Mailing Address - State:MI
Mailing Address - Zip Code:49660-9352
Mailing Address - Country:US
Mailing Address - Phone:231-398-1760
Mailing Address - Fax:
Practice Address - Street 1:1293 E PARKDALE AVE
Practice Address - Street 2:
Practice Address - City:MANISTEE
Practice Address - State:MI
Practice Address - Zip Code:49660-8904
Practice Address - Country:US
Practice Address - Phone:231-398-1840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-12
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012020880207R00000X
MI5101021764207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine