Provider Demographics
NPI:1043262496
Name:VANDYCK, CHARLES TUCKER (OD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:TUCKER
Last Name:VANDYCK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9239 W CENTER RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68124-1900
Mailing Address - Country:US
Mailing Address - Phone:402-898-3232
Mailing Address - Fax:402-898-3234
Practice Address - Street 1:9239 W CENTER RD
Practice Address - Street 2:SUITE 103
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68124-1900
Practice Address - Country:US
Practice Address - Phone:402-898-3232
Practice Address - Fax:402-898-3234
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2011-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0601800375152W00000X
CO5514T2426152W00000X
LA1388152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1476471Medicaid
VA9237330Medicaid
CO06421052Medicaid
KY710115320Medicaid
G02638W02Medicare PIN
VA8L15913Medicare PIN
DC154974ZD26Medicare PIN
VA9237330Medicaid
P00765997Medicare PIN
KY710115320Medicaid
P00249007Medicare PIN
VA001179W00Medicare ID - Type UnspecifiedINDIVIDUAL MEDICARE NUMBE
LA4M996CM55Medicare PIN
LA4B308Medicare ID - Type Unspecified
LA1476471Medicaid
LA4M996CM68Medicare PIN
LA4B309Medicare ID - Type Unspecified
VA020873L96Medicare PIN
KY01436022Medicare PIN