Provider Demographics
NPI:1760695449
Name:VANDEN BERGE, KEVIN MARINUS (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:MARINUS
Last Name:VANDEN BERGE
Suffix:
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:PO BOX 2576
Mailing Address - Street 2:
Mailing Address - City:STEPHENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76401-0043
Mailing Address - Country:US
Mailing Address - Phone:254-968-0292
Mailing Address - Fax:
Practice Address - Street 1:351 E TARLETON ST
Practice Address - Street 2:
Practice Address - City:STEPHENVILLE
Practice Address - State:TX
Practice Address - Zip Code:76401-3511
Practice Address - Country:US
Practice Address - Phone:254-968-0292
Practice Address - Fax:888-289-1607
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP 2247799-54061390200000X
TXN2329207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
8CU164OtherBLUE CROSS
TX281982301Medicaid
TXTXB129515Medicare PIN