Healthcare Provider Details

I. General information

NPI: 1003923012
Provider Name (Legal Business Name): STEPHEN J VANDYKE OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 12/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 ANNE ST NW
BEMIDJI MN
56601-5114
US

IV. Provider business mailing address

1611 ANNE ST NW
BEMIDJI MN
56601-5114
US

V. Phone/Fax

Practice location:
  • Phone: 218-333-2020
  • Fax: 218-333-2019
Mailing address:
  • Phone: 218-333-2020
  • Fax: 218-333-2019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number1839
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1839
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: