MEDICARE: DR. LARRY J VANDAALEN MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	6837	PR

General Provider Information

NPI Number	:	1457341240
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LARRY J VANDAALEN MD

Provider Business Mailing Address
First Line	:	1353 CARR 19
Second Line	:	PMB 139
City	:	GUAYNABO
State	:	PR
Zip	:	00966-2700
Country	:	US
Telephone Number	:	787-793-0440
Fax Number	:	787-781-2766

Provider Business Practice Location Address
First Line	:	CARR 21
Second Line	:	NO U-3-4 LAS LOMAS
City	:	RIO PIEDRAS
State	:	PR
Zip	:	00921-0000
Country	:	US
Telephone Number	:	787-793-0440
Fax Number	:	787-781-2766

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/24/2005
Last Update Date	:	02/13/2008

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