Provider Demographics
NPI:1902291818
Name:VELDKAMP, TYLER
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:VELDKAMP
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:944 CENTER AVE
Mailing Address - Street 2:PO BOX 700255
Mailing Address - City:OOSTBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53070-1354
Mailing Address - Country:US
Mailing Address - Phone:920-889-1067
Mailing Address - Fax:
Practice Address - Street 1:2835 N GRANDVIEW BLVD STE 300
Practice Address - Street 2:
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-5591
Practice Address - Country:US
Practice Address - Phone:262-542-3779
Practice Address - Fax:262-542-4428
Is Sole Proprietor?:No
Enumeration Date:2015-03-30
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WI1131-25213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100080538Medicaid