Basic Information
Provider Information
NPI: 1003009986
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: VANDONGEN
FirstName: DANIQUE
MiddleName: LYSANNE
NamePrefix: DR.
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 520
Address2:  
City: KATY
State: TX
PostalCode: 774920520
CountryCode: US
TelephoneNumber: 8324613330
FaxNumber: 8618118124
Practice Location
Address1: 21720 KINGSLAND BLVD
Address2: SUITE 102
City: KATY
State: TX
PostalCode: 774502550
CountryCode: US
TelephoneNumber: 2815795532
FaxNumber: 8668118124
Other Information
ProviderEnumerationDate: 08/23/2007
LastUpdateDate: 10/01/2014
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
174400000XM6929TXY Other Service ProvidersSpecialist 

No ID Information.


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