Healthcare Provider Details

I. General information

NPI: 1386724375
Provider Name (Legal Business Name): JACQUELYN VANDER WALL MD. INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 04/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 TECHNOLOGY DR
IRVINE CA
92618-2302
US

IV. Provider business mailing address

3460 KATELLA AVE
LOS ALAMITOS CA
90720-2334
US

V. Phone/Fax

Practice location:
  • Phone: 949-923-3250
  • Fax: 855-812-5865
Mailing address:
  • Phone: 562-594-6599
  • Fax: 562-598-7116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberG065045
License Number StateCA

VIII. Authorized Official

Name: JACQUELYN LEE VANDER WALL
Title or Position: MD
Credential: M.D.
Phone: 562-594-6599