Provider Demographics
NPI:1851344642
Name:VANDERLOOP, DAVID G II (OD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:G
Last Name:VANDERLOOP
Suffix:II
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 1:823 GRIGNON ST
Mailing Address - Street 2:
Mailing Address - City:KAUKAUNA
Mailing Address - State:WI
Mailing Address - Zip Code:54130-1643
Mailing Address - Country:US
Mailing Address - Phone:920-205-5810
Mailing Address - Fax:
Practice Address - Street 1:1901 CROOKS AVE STE C
Practice Address - Street 2:
Practice Address - City:KAUKAUNA
Practice Address - State:WI
Practice Address - Zip Code:54130-3200
Practice Address - Country:US
Practice Address - Phone:920-372-2555
Practice Address - Fax:920-949-4025
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2018-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2991152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38624300Medicaid
WI0000447240Medicare ID - Type Unspecified
WIV03732Medicare UPIN