Provider Demographics
NPI:1861508624
Name:VANKEUREN, JOSEPH (OD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:
Last Name:VANKEUREN
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 1:1212 ABBE ROAD NORTH
Mailing Address - Street 2:STE B
Mailing Address - City:ELYRIA
Mailing Address - State:OH
Mailing Address - Zip Code:44035
Mailing Address - Country:US
Mailing Address - Phone:440-365-2021
Mailing Address - Fax:440-365-2033
Practice Address - Street 1:1212 ABBE ROAD NORTH
Practice Address - Street 2:STE B
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035
Practice Address - Country:US
Practice Address - Phone:440-365-2021
Practice Address - Fax:440-365-2033
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2010-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4057T121152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0773551Medicaid
OH0494870001Medicare NSC
OH0773551Medicaid
OH410017787Medicare PIN
OH0664551Medicare PIN