Healthcare Provider Details

I. General information

NPI: 1861694812
Provider Name (Legal Business Name): VERMILLION VISION CLINIC, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2007
Last Update Date: 03/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 W MAIN ST
VERMILLION SD
57069-3036
US

IV. Provider business mailing address

120 W MAIN ST
VERMILLION SD
57069-3036
US

V. Phone/Fax

Practice location:
  • Phone: 605-624-4291
  • Fax: 605-624-6822
Mailing address:
  • Phone: 605-624-4291
  • Fax: 605-624-6822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number578
License Number StateSD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier11321
Identifier TypeOTHER
Identifier StateSD
Identifier IssuerAVERA HEALTH
# 2
Identifier9219420
Identifier TypeOTHER
Identifier StateSD
Identifier IssuerDAKOTACARE GROUP
# 3
IdentifierOP2175
Identifier TypeOTHER
Identifier StateSD
Identifier IssuerEYEMED
# 4
Identifier32866
Identifier TypeOTHER
Identifier StateSD
Identifier IssuerSANFORD HEALTH GROUP
# 5
Identifier9200863
Identifier TypeMEDICAID
Identifier StateSD
Identifier Issuer
# 6
Identifier399493
Identifier TypeOTHER
Identifier State
Identifier IssuerCOVENTRY HEALTH CARE OF IOWA
# 7
Identifier238521
Identifier TypeOTHER
Identifier StateSD
Identifier IssuerMIDLANDS CHOICE, AETNA, CIGNA
# 8
Identifier4995791
Identifier TypeOTHER
Identifier StateSD
Identifier IssuerBLUE SHIELD GROUP
# 9
Identifier2100851
Identifier TypeOTHER
Identifier StateSD
Identifier IssuerMEDICA UNITED HEALTHCARE
# 10
Identifier6056244291
Identifier TypeOTHER
Identifier StateSD
Identifier IssuerVSP

VIII. Authorized Official

Name: DR. AMY M DEJONG
Title or Position: PRESIDENT
Credential: O.D.
Phone: 605-624-4291