Provider Demographics
NPI:1386613990
Name:VANDER BROEK, DALE (DO)
Entity type:Individual
Prefix:
First Name:DALE
Middle Name:
Last Name:VANDER BROEK
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 1:2 DEER RUN DR
Mailing Address - Street 2:
Mailing Address - City:PELLA
Mailing Address - State:IA
Mailing Address - Zip Code:50219-1356
Mailing Address - Country:US
Mailing Address - Phone:641-780-1202
Mailing Address - Fax:
Practice Address - Street 1:2 DEER RUN DR
Practice Address - Street 2:
Practice Address - City:PELLA
Practice Address - State:IA
Practice Address - Zip Code:50219-1356
Practice Address - Country:US
Practice Address - Phone:641-780-1202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-16
Last Update Date:2014-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02411207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA110128512OtherRAILROAD MEDICARE
IA2067256Medicaid
IA110128512OtherRAILROAD MEDICARE
IA56098Medicare PIN
IA56098Medicare ID - Type UnspecifiedMEDICARE NUMBER