Provider Demographics
NPI:1679541072
Name:VANDER BROEK, NANCY A (DO)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:A
Last Name:VANDER BROEK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:PELLA
Mailing Address - State:IA
Mailing Address - Zip Code:50219-1189
Mailing Address - Country:US
Mailing Address - Phone:641-628-3832
Mailing Address - Fax:641-628-8894
Practice Address - Street 1:405 MONROE ST
Practice Address - Street 2:
Practice Address - City:PELLA
Practice Address - State:IA
Practice Address - Zip Code:50219-1189
Practice Address - Country:US
Practice Address - Phone:641-628-3832
Practice Address - Fax:641-628-8894
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02420208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1064832Medicaid
IA080099542OtherRAILROAD MEDICARE
IA56088Medicare PIN
IA080099542OtherRAILROAD MEDICARE
IA56088Medicare ID - Type UnspecifiedMEDICARE #