Provider Demographics
NPI:1013997147
Name:DEJONG, AMY M (OD)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:M
Last Name:DEJONG
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 1:120 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:VERMILLION
Mailing Address - State:SD
Mailing Address - Zip Code:57069-3036
Mailing Address - Country:US
Mailing Address - Phone:605-624-4291
Mailing Address - Fax:604-624-6822
Practice Address - Street 1:120 W MAIN ST
Practice Address - Street 2:
Practice Address - City:VERMILLION
Practice Address - State:SD
Practice Address - Zip Code:57069-3036
Practice Address - Country:US
Practice Address - Phone:605-624-4291
Practice Address - Fax:604-624-6822
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2015-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD578152W00000X
IA02198152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD238521OtherMIDLANDS CHOICE, AETNA, CIGNA
399493OtherCOVENTRY HEALTH CARE OF IOWA
SD4995791OtherBLUE SHIELD PROVIDER
SD32866OtherSANFORD HEALTH PLAN
SD9219420OtherDAKOTACARE GROUP NUMBER
SD11321OtherAVERA HEALTH PLANS
SD200648368OtherTRICARE/TRIWEST PROVIDER
SD578OtherDAKOTACARE PIN
SDOP2175OtherEYEMED
SD578OtherDAKOTACARE PROVIDER NUMBE
SD2203601OtherMEDICA UNITEDHEALTHCARE
SD6056244291OtherVISION SERVICE PLAN
SDI3186OtherSANFORD PIN
SD9200863Medicaid
SDP01260966Medicare PIN
SD578OtherDAKOTACARE PROVIDER NUMBE
SD578OtherDAKOTACARE PIN
SD41823Medicare PIN
SD32866OtherSANFORD HEALTH PLAN