Provider Demographics
NPI:1033868419
Name:WALDVOGEL, VANESSA JO
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:JO
Last Name:WALDVOGEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 N MAIN ST STE 600
Mailing Address - Street 2:
Mailing Address - City:CHELSEA
Mailing Address - State:MI
Mailing Address - Zip Code:48118-1703
Mailing Address - Country:US
Mailing Address - Phone:734-385-7255
Mailing Address - Fax:734-274-4925
Practice Address - Street 1:420 N MAIN ST STE 600
Practice Address - Street 2:
Practice Address - City:CHELSEA
Practice Address - State:MI
Practice Address - Zip Code:48118-1703
Practice Address - Country:US
Practice Address - Phone:734-385-7255
Practice Address - Fax:734-274-4925
Is Sole Proprietor?:No
Enumeration Date:2022-03-22
Last Update Date:2025-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601011706207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085.008947OtherILLINOIS DEPARTMENT OF FINANCIAL AND PROFESSIONAL REGULATION