Provider Demographics
NPI:1447330980
Name:VANDER LEEST, TARRA L (OD)
Entity type:Individual
Prefix:
First Name:TARRA
Middle Name:L
Last Name:VANDER LEEST
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3135 SUNNER AVE
Mailing Address - Street 2:
Mailing Address - City:SPIRIT LAKE
Mailing Address - State:IA
Mailing Address - Zip Code:51360-7678
Mailing Address - Country:US
Mailing Address - Phone:712-330-0276
Mailing Address - Fax:
Practice Address - Street 1:1306 18TH ST
Practice Address - Street 2:SUITE E
Practice Address - City:SPIRIT LAKE
Practice Address - State:IA
Practice Address - Zip Code:51360-1163
Practice Address - Country:US
Practice Address - Phone:712-336-4401
Practice Address - Fax:712-336-4403
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2023-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02288152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IB2643001Medicare PIN