Healthcare Provider Details

I. General information

NPI: 1265441554
Provider Name (Legal Business Name): JEROME ROBERT VONDERHAAR OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 LANDMARK DR SIUTE 380
BELLEVUE KY
41073-1393
US

IV. Provider business mailing address

1617 HILLTREE DR
CINCINNATI OH
45255-3200
US

V. Phone/Fax

Practice location:
  • Phone: 859-392-3970
  • Fax:
Mailing address:
  • Phone: 513-474-8442
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number1561
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberR2471
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: