Provider Demographics
NPI:1982600441
Name:VANDENBERGE, GLEN C (OD)
Entity Type:Individual
Prefix:DR
First Name:GLEN
Middle Name:C
Last Name:VANDENBERGE
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 1:416 VALLEY VIEW DR # 100
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBLUFF
Mailing Address - State:NE
Mailing Address - Zip Code:69361-1486
Mailing Address - Country:US
Mailing Address - Phone:308-635-1633
Mailing Address - Fax:308-635-2880
Practice Address - Street 1:416 VALLEY VIEW DR # 100
Practice Address - Street 2:
Practice Address - City:SCOTTSBLUFF
Practice Address - State:NE
Practice Address - Zip Code:69361-1486
Practice Address - Country:US
Practice Address - Phone:308-635-1633
Practice Address - Fax:308-635-2880
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE797152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1982600441OtherDR. VANDENBERGE NPI
NE1710903984OtherGROUP NPI
NE$$$$$$$$$Medicaid
1982600441OtherDR. VANDENBERGE NPI
NET74871Medicare UPIN
CQ4076Medicare PIN