Provider Demographics
NPI:1902887631
Name:VANDEWEGE, GARY (MD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:VANDEWEGE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:600 E FRANCIS ST
Mailing Address - Street 2:SUITE #3
Mailing Address - City:NORTH PLATTE
Mailing Address - State:NE
Mailing Address - Zip Code:69101-6796
Mailing Address - Country:US
Mailing Address - Phone:308-532-6906
Mailing Address - Fax:308-532-6964
Practice Address - Street 1:600 E FRANCIS ST
Practice Address - Street 2:SUITE #3
Practice Address - City:NORTH PLATTE
Practice Address - State:NE
Practice Address - Zip Code:69101-6796
Practice Address - Country:US
Practice Address - Phone:308-532-6906
Practice Address - Fax:308-532-6964
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NE14415207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
B90797Medicare UPIN