Healthcare Provider Details

I. General information

NPI: 1477567402
Provider Name (Legal Business Name): COREY J VANDE ZANDSCHULP M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 11/21/2025
Certification Date: 11/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4103 MERCANTILE DR
LAKE OSWEGO OR
97035
US

IV. Provider business mailing address

4103 MERCANTILE DR
LAKE OSWEGO OR
97035-2556
US

V. Phone/Fax

Practice location:
  • Phone: 503-850-9940
  • Fax: 503-850-6709
Mailing address:
  • Phone: 503-850-9940
  • Fax: 503-850-6709

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMD24129
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD24129
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License NumberMD6143532
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: