Provider Demographics
NPI:1952591711
Name:VANDEN BERG, MA THERESA L (MD)
Entity Type:Individual
Prefix:DR
First Name:MA
Middle Name:THERESA L
Last Name:VANDEN BERG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MA THERESA
Other - Middle Name:
Other - Last Name:CONCEPCION
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 3002
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-0302
Mailing Address - Country:US
Mailing Address - Phone:360-747-5800
Mailing Address - Fax:360-575-3846
Practice Address - Street 1:1718 E KESSLER BLVD
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-1842
Practice Address - Country:US
Practice Address - Phone:360-747-5800
Practice Address - Fax:360-575-3846
Is Sole Proprietor?:No
Enumeration Date:2007-07-27
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301089956207Q00000X
WAMD60120609207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0263926OtherL & I /CRIME VICTIMS
OR500624616Medicaid
WA2008004Medicaid
WA2008004Medicaid