Provider Demographics
NPI:1932191756
Name:VAN DER HEYDEN, TERRY R (OD)
Entity type:Individual
Prefix:DR
First Name:TERRY
Middle Name:R
Last Name:VAN DER HEYDEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4060 TAMIAMI TRL N
Mailing Address - Street 2:SUITE 4
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34103-3596
Mailing Address - Country:US
Mailing Address - Phone:239-261-5915
Mailing Address - Fax:
Practice Address - Street 1:4060 TAMIAMI TRL N
Practice Address - Street 2:SUITE 4
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34103-3596
Practice Address - Country:US
Practice Address - Phone:239-261-5915
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-17
Last Update Date:2010-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC001061152WC0802X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL410013850OtherRAILROAD MEDICARE
FL410013850OtherRAILROAD MEDICARE
0600750001Medicare NSC
19773Medicare PIN