Healthcare Provider Details

I. General information

NPI: 1730562422
Provider Name (Legal Business Name): JONATHAN CHRISTIAN VANDENBERG D.O
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2015
Last Update Date: 03/31/2021
Certification Date: 03/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 WEALTHY ST SE
GRAND RAPIDS MI
49503-5247
US

IV. Provider business mailing address

1331 MOURSUND AVENUE BLDG. G RM 115-118
HOUSTON TX
77030-5389
US

V. Phone/Fax

Practice location:
  • Phone: 616-840-8805
  • Fax: 616-840-9642
Mailing address:
  • Phone: 713-799-5033
  • Fax: 713-797-5982

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number5101025744
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number125.066293
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: