Healthcare Provider Details

I. General information

NPI: 1245201805
Provider Name (Legal Business Name): BENJAMIN HENRY VANDERZWAAG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

575 LINCOLN SUITE 310
NAPA CA
94558
US

IV. Provider business mailing address

2365 WESTLAKE DR
KELSEYVILLE CA
95451-7055
US

V. Phone/Fax

Practice location:
  • Phone: 707-256-3800
  • Fax: 707-256-3508
Mailing address:
  • Phone: 707-279-2078
  • Fax: 707-279-0890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberC33747
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: