Provider Demographics
NPI:1205399607
Name:VONDRAK, ERIC (DO)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:VONDRAK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:338 S DAKOTA AVE
Mailing Address - Street 2:
Mailing Address - City:VANDENBERG AFB
Mailing Address - State:CA
Mailing Address - Zip Code:93437-6307
Mailing Address - Country:US
Mailing Address - Phone:805-606-1601
Mailing Address - Fax:
Practice Address - Street 1:338 S DAKOTA AVE
Practice Address - Street 2:
Practice Address - City:VANDENBERG AFB
Practice Address - State:CA
Practice Address - Zip Code:93437-6307
Practice Address - Country:US
Practice Address - Phone:805-606-1601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-11
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2262207QA0505X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program