Provider Demographics
NPI:1528264603
Name:VANDEWYNGAERDE, TARA NICOLE (OD)
Entity type:Individual
Prefix:DR
First Name:TARA
Middle Name:NICOLE
Last Name:VANDEWYNGAERDE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:807 CLARK ST
Mailing Address - Street 2:
Mailing Address - City:OGLESBY
Mailing Address - State:IL
Mailing Address - Zip Code:61348-1177
Mailing Address - Country:US
Mailing Address - Phone:815-228-7623
Mailing Address - Fax:
Practice Address - Street 1:700 14TH AVE
Practice Address - Street 2:
Practice Address - City:MENDOTA
Practice Address - State:IL
Practice Address - Zip Code:61342-1412
Practice Address - Country:US
Practice Address - Phone:815-539-6291
Practice Address - Fax:815-539-3035
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-25
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILPENDING152W00000X
IL46009989152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1215128806Medicare PIN
IL5997220001Medicare NSC