Healthcare Provider Details

I. General information

NPI: 1174524144
Provider Name (Legal Business Name): LARRY L VANDERZEE OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 09/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5116 S WESTERN AVE
SIOUX FALLS SD
57108-2677
US

IV. Provider business mailing address

5116 S WESTERN AVE
SIOUX FALLS SD
57108-2677
US

V. Phone/Fax

Practice location:
  • Phone: 605-338-7104
  • Fax: 605-575-3880
Mailing address:
  • Phone: 605-338-7104
  • Fax: 605-575-3880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number486
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: