Provider Demographics
NPI:1972569929
Name:VANDER BIE, DAVID ALYN (DPM)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:ALYN
Last Name:VANDER BIE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1508 WEST CENTRE STREET
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024
Mailing Address - Country:US
Mailing Address - Phone:269-327-4447
Mailing Address - Fax:269-327-3120
Practice Address - Street 1:1508 WEST CENTRE STREET
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024
Practice Address - Country:US
Practice Address - Phone:269-327-4447
Practice Address - Fax:269-327-3120
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901001113213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
9395000OtherBCBSM
2730324OtherPHP
MI1689800Medicaid
9395000OtherBCN
T33989Medicare UPIN
2730324OtherPHP