Healthcare Provider Details

I. General information

NPI: 1053793836
Provider Name (Legal Business Name): AUSTIN MAURICE VANDEBERG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2015
Last Update Date: 02/28/2025
Certification Date: 02/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6071 E WOODMEN RD STE 105
COLORADO SPRINGS CO
80923-2610
US

IV. Provider business mailing address

PO BOX 35380
LAS VEGAS NV
89133-5380
US

V. Phone/Fax

Practice location:
  • Phone: 719-597-8704
  • Fax:
Mailing address:
  • Phone: 719-538-2900
  • Fax: 719-538-2990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number7589
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberDR.0060771
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: