Provider Demographics
NPI:1972673747
Name:VANDERBOSCH, LEONARD J (MD)
Entity Type:Individual
Prefix:MR
First Name:LEONARD
Middle Name:J
Last Name:VANDERBOSCH
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:PO BOX 2808
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99220
Mailing Address - Country:US
Mailing Address - Phone:509-688-6733
Mailing Address - Fax:509-688-6777
Practice Address - Street 1:1003 E TRENT AVE
Practice Address - Street 2:STE 150
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99202-2180
Practice Address - Country:US
Practice Address - Phone:509-688-6733
Practice Address - Fax:509-688-6777
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2007-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00010451207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAE17412Medicare UPIN