Provider Demographics
NPI:1336438514
Name:VANDENBOSCH, NICHOLAS ALAN (DO)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:ALAN
Last Name:VANDENBOSCH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1847
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49443-1847
Mailing Address - Country:US
Mailing Address - Phone:866-611-1512
Mailing Address - Fax:231-728-4789
Practice Address - Street 1:1223 MERCY DR
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-1829
Practice Address - Country:US
Practice Address - Phone:231-672-3177
Practice Address - Fax:231-672-3178
Is Sole Proprietor?:No
Enumeration Date:2011-03-28
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101019297207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN28430104OtherMEDICARE PTAN