Basic Information
| Provider Information | |||||||||
| NPI: | 1194710541 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VANDERVEEN | ||||||||
| FirstName: | KATRINA | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 620 W EDISON RD | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | MISHAWAKA | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465452784 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742581100 | ||||||||
| FaxNumber: | 5742581101 | ||||||||
| Practice Location | |||||||||
| Address1: | 620 W EDISON RD | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | MISHAWAKA | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465452784 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742581100 | ||||||||
| FaxNumber: | 5742581101 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2005 | ||||||||
| LastUpdateDate: | 05/16/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 01058810 | IN | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085B0100X | 01058810 | IN | N | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085N0700X | 01058810 | IN | N | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085N0904X | 01058810 | IN | N | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085P0229X | 01058810 | IN | N | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology | 2085R0203X | 01058810 | IN | N | Allopathic & Osteopathic Physicians | Radiology | Therapeutic Radiology | 2085R0204X | 01058810 | IN | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085U0001X | 01058810 | IN | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound |
ID Information
| ID | Type | State | Issuer | Description | 200473380 | 05 | IN | MEDICAID |