Healthcare Provider Details

I. General information

NPI: 1609872795
Provider Name (Legal Business Name): JAMES CRAIG VANDEWALL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2005
Last Update Date: 07/05/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 N 8TH ST
OLEAN NY
14760-2237
US

IV. Provider business mailing address

415 N 8TH ST P.O. BOX 1208
OLEAN NY
14760-6208
US

V. Phone/Fax

Practice location:
  • Phone: 716-372-9399
  • Fax: 716-373-5530
Mailing address:
  • Phone: 716-372-9399
  • Fax: 716-373-5530

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number195467
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number195467-1
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierP00079354
Identifier TypeOTHER
Identifier StateNY
Identifier IssuerRR MEDICARE
# 2
Identifier01482237
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: