Provider Demographics
NPI:1821087453
Name:DENCKLAU, VERNON EVERETT (DO)
Entity Type:Individual
Prefix:
First Name:VERNON
Middle Name:EVERETT
Last Name:DENCKLAU
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:1107 STONE ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-3569
Mailing Address - Country:US
Mailing Address - Phone:810-989-6113
Mailing Address - Fax:810-989-6117
Practice Address - Street 1:1107 STONE ST
Practice Address - Street 2:SUITE 1
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3569
Practice Address - Country:US
Practice Address - Phone:810-989-6113
Practice Address - Fax:810-989-6117
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-17
Last Update Date:2008-08-20
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI5101007542208G00000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
B47397Medicare UPIN