Healthcare Provider Details

I. General information

NPI: 1023190220
Provider Name (Legal Business Name): STEVEN CRAIG VANDER WAAL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 05/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3619 HIGHWAY 101 N
GEARHART OR
97138-4321
US

IV. Provider business mailing address

3619 HIGHWAY 101 N
GEARHART OR
97138-4321
US

V. Phone/Fax

Practice location:
  • Phone: 503-738-3832
  • Fax: 503-738-3466
Mailing address:
  • Phone: 503-738-3832
  • Fax: 503-738-3466

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number13959
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number13959
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: