Provider Demographics
NPI:1396162749
Name:VANDERBUSH, BROCK D (MD)
Entity type:Individual
Prefix:
First Name:BROCK
Middle Name:D
Last Name:VANDERBUSH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:317-962-3834
Mailing Address - Fax:
Practice Address - Street 1:6820 PARKDALE PL STE 212
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-6600
Practice Address - Country:US
Practice Address - Phone:317-216-2700
Practice Address - Fax:317-216-2777
Is Sole Proprietor?:No
Enumeration Date:2014-03-24
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IN01082307A207QS0010X, 207Q00000X
GA82220207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine