Provider Demographics
NPI:1699749481
Name:VANDENHEEDE, LAURA L (MD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:L
Last Name:VANDENHEEDE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5658 HIGHWAY 260
Mailing Address - Street 2:SUITE 7
Mailing Address - City:LAKESIDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85929-5189
Mailing Address - Country:US
Mailing Address - Phone:928-537-3399
Mailing Address - Fax:928-537-0475
Practice Address - Street 1:5658 HIGHWAY 260
Practice Address - Street 2:SUITE 7
Practice Address - City:LAKESIDE
Practice Address - State:AZ
Practice Address - Zip Code:85929-5189
Practice Address - Country:US
Practice Address - Phone:928-537-3399
Practice Address - Fax:928-537-0475
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-16
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ26282207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARZ1096282OtherSTATE COMP FUND
AR418021Medicaid
BV5769128OtherDEA
AZZ60963Medicare PIN
G66984Medicare UPIN
AR418021Medicaid