Provider Demographics
NPI:1740061621
Name:VANDERFELTZ, COLE EDWARD (OD)
Entity type:Individual
Prefix:
First Name:COLE
Middle Name:EDWARD
Last Name:VANDERFELTZ
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 1:500 N KEENE ST STE 103
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-8104
Mailing Address - Country:US
Mailing Address - Phone:573-874-2030
Mailing Address - Fax:573-449-0253
Practice Address - Street 1:202 E NORTH ST
Practice Address - Street 2:
Practice Address - City:CALIFORNIA
Practice Address - State:MO
Practice Address - Zip Code:65018-1583
Practice Address - Country:US
Practice Address - Phone:573-874-2030
Practice Address - Fax:573-449-0253
Is Sole Proprietor?:No
Enumeration Date:2023-10-09
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MO2024018653152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program