Healthcare Provider Details

I. General information

NPI: 1598186538
Provider Name (Legal Business Name): DAN VANDERIET M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2013
Last Update Date: 12/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 MARIYANA ST
GALLUP NM
87301-5635
US

IV. Provider business mailing address

2401 MARIYANA ST
GALLUP NM
87301-5635
US

V. Phone/Fax

Practice location:
  • Phone: 505-726-8360
  • Fax:
Mailing address:
  • Phone: 505-726-8360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301051395
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: