Provider Demographics
NPI:1265416671
Name:DEHAAN, FRED (OD)
Entity type:Individual
Prefix:
First Name:FRED
Middle Name:
Last Name:DEHAAN
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 1:3110 LEONA DR
Mailing Address - Street 2:
Mailing Address - City:STORM LAKE
Mailing Address - State:IA
Mailing Address - Zip Code:50588-2751
Mailing Address - Country:US
Mailing Address - Phone:712-732-3308
Mailing Address - Fax:
Practice Address - Street 1:600 ONTARIO ST
Practice Address - Street 2:
Practice Address - City:STORM LAKE
Practice Address - State:IA
Practice Address - Zip Code:50588-1845
Practice Address - Country:US
Practice Address - Phone:712-732-3233
Practice Address - Fax:712-732-1866
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1642152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1165332Medicaid
IA1165332Medicaid
IA165332Medicare ID - Type UnspecifiedDOCTOR ID NUMBER