Provider Demographics
NPI:1871686733
Name:VANDENBOSCH, MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:VANDENBOSCH
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 1:2844 EVENING ROCK ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89135-1631
Mailing Address - Country:US
Mailing Address - Phone:321-698-6853
Mailing Address - Fax:702-818-3452
Practice Address - Street 1:1330 S VALLEY VIEW BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-1865
Practice Address - Country:US
Practice Address - Phone:702-675-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME64003207L00000X
NV14668207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL374010200Medicaid
NVV109104Medicare PIN
FL23599WMedicare PIN
FL23599ZMedicare PIN
FL374010200Medicaid
FL23599XMedicare PIN