Healthcare Provider Details

I. General information

NPI: 1821475427
Provider Name (Legal Business Name): WILLIAM D VANDECAR IV M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2015
Last Update Date: 02/06/2026
Certification Date: 02/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 MONROE PARKWAY SUITE 160
LAKE OSWERGO OR
97035
US

IV. Provider business mailing address

PO BOX 22009
PORTLAND OR
97269
US

V. Phone/Fax

Practice location:
  • Phone: 503-636-2551
  • Fax: 503-636-3055
Mailing address:
  • Phone: 503-558-7372
  • Fax: 503-344-5140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number8219851
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberMD61417092
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberMD228671
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: