Healthcare Provider Details

I. General information

NPI: 1417000852
Provider Name (Legal Business Name): LEWIS A VANOSDEL III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2007
Last Update Date: 01/17/2020
Certification Date: 01/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1033 SW 152ND ST NAVOS SUNSTONE YOUTH RESIDENTIAL
BURIEN WA
98166
US

IV. Provider business mailing address

11602 SW BREYMAN AVE
PORTLAND OR
97219-8400
US

V. Phone/Fax

Practice location:
  • Phone: 206-829-1121
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberG33962
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number9213117-1205
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberG-33962
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberMD00033116
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: