Provider Demographics
NPI:1730248881
Name:VANKESTEREN, JOHN LOGAN (OD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:LOGAN
Last Name:VANKESTEREN
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 1:3707 CAMINO DON DIEGO NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-3905
Mailing Address - Country:US
Mailing Address - Phone:505-275-1537
Mailing Address - Fax:
Practice Address - Street 1:400 EUBANK BLVD NE
Practice Address - Street 2:SUITE A
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87123-2758
Practice Address - Country:US
Practice Address - Phone:505-293-0417
Practice Address - Fax:505-293-4761
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM552152W00000X
CO2306152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMV04183Medicare UPIN