Healthcare Provider Details

I. General information

NPI: 1811996846
Provider Name (Legal Business Name): ROBERT R. VANDERZWAAG JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2005
Last Update Date: 01/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5314 LINCOLNWAY EAST
MISHAWAKA IN
46544-4249
US

IV. Provider business mailing address

PO BOX 1887
ELKHART IN
46515-1887
US

V. Phone/Fax

Practice location:
  • Phone: 574-256-9032
  • Fax: 574-256-9049
Mailing address:
  • Phone: 574-389-0542
  • Fax: 574-522-8505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01048973A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: