Provider Demographics
NPI:1699704320
Name:VANDERVORT, VICKY JOHNS (OD)
Entity type:Individual
Prefix:
First Name:VICKY
Middle Name:JOHNS
Last Name:VANDERVORT
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 1:9900 NICHOLAS ST
Mailing Address - Street 2:STE 250
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68114-2261
Mailing Address - Country:US
Mailing Address - Phone:402-493-6500
Mailing Address - Fax:
Practice Address - Street 1:9900 NICHOLAS ST
Practice Address - Street 2:STE 275
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-2149
Practice Address - Country:US
Practice Address - Phone:402-493-6500
Practice Address - Fax:402-493-4370
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE927152WV0400X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA2988394Medicaid
IA90A30OtherBCBS
NE10025382400Medicaid
NE37111OtherNEBRASKA BC/BS
IA90A30OtherBCBS
IA2988394Medicaid