Provider Demographics
NPI:1285800821
Name:TERRY R. VANDERHEYDEN OD
Entity type:Organization
Organization Name:TERRY R. VANDERHEYDEN OD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:R
Authorized Official - Last Name:VANDERHEYDEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:239-261-5915
Mailing Address - Street 1:4060 TAMIAMI TRL N
Mailing Address - Street 2:SUITE 4
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34103-3596
Mailing Address - Country:US
Mailing Address - Phone:239-261-5915
Mailing Address - Fax:
Practice Address - Street 1:4060 TAMIAMI TRL N
Practice Address - Street 2:SUITE 4
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34103-3596
Practice Address - Country:US
Practice Address - Phone:239-261-5915
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-04
Last Update Date:2010-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC001061332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
T84002Medicare UPIN
FL19773Medicare PIN
0600750001Medicare NSC