Provider Demographics
NPI:1003923012
Name:VANDYKE, STEPHEN J (OD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:J
Last Name:VANDYKE
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 1:1611 ANNE ST NW
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-5114
Mailing Address - Country:US
Mailing Address - Phone:218-333-2020
Mailing Address - Fax:218-333-2019
Practice Address - Street 1:1611 ANNE ST NW
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-5114
Practice Address - Country:US
Practice Address - Phone:218-333-2020
Practice Address - Fax:218-333-2019
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2011-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1839152WC0802X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
10723OtherND BCBS
MN016323600Medicaid
934731OtherAMERICAS PPO
HP17316OtherHEALTHPARTNERS
2219746OtherMEDICA
49B66VAOtherMN BCBS
912049OtherPREFERREDONE
MN410000911Medicare ID - Type Unspecified
HP17316OtherHEALTHPARTNERS