Healthcare Provider Details

I. General information

NPI: 1295727345
Provider Name (Legal Business Name): STEVEN JAMES VANDENBERG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2005
Last Update Date: 07/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 N MEADE ST
APPLETON WI
54911-3762
US

IV. Provider business mailing address

1520 N MEADE ST
APPLETON WI
54911-3762
US

V. Phone/Fax

Practice location:
  • Phone: 920-734-7181
  • Fax: 920-734-0621
Mailing address:
  • Phone: 920-991-0188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number35659
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: