Provider Demographics
NPI:1952446924
Name:VANDEN BOOM, VALERIE M (OD)
Entity Type:Individual
Prefix:DR
First Name:VALERIE
Middle Name:M
Last Name:VANDEN BOOM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7478 MEADOWRUE CIR
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562-4189
Mailing Address - Country:US
Mailing Address - Phone:608-836-7285
Mailing Address - Fax:
Practice Address - Street 1:7428 MINERAL POINT RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53717-1710
Practice Address - Country:US
Practice Address - Phone:608-833-3937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2395152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIU10108Medicare UPIN