Healthcare Provider Details

I. General information

NPI: 1881803971
Provider Name (Legal Business Name): HARRY RALPH VANDERWAL JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 N 2ND AVE STE 100
SANDPOINT ID
83864-1565
US

IV. Provider business mailing address

420 N 2ND AVE STE 100
SANDPOINT ID
83864-1552
US

V. Phone/Fax

Practice location:
  • Phone: 208-265-2242
  • Fax: 208-265-8214
Mailing address:
  • Phone: 208-265-2242
  • Fax: 208-265-8214

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberM 9823
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: