MEDICARE: DR. TREVOR DOUGLAS VAN DE WATER 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	207LP2900X	Pain Medicine (Anesthesiology) Physician	D0099403	MD
2	390200000X	Student in an Organized Health Care Education/Training Program
3	207LP2900X	Pain Medicine (Anesthesiology) Physician	2025-01885	NC
4	207L00000X	Anesthesiology Physician	11977	GA

General Provider Information

NPI Number	:	1487278875
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TREVOR DOUGLAS VAN DE WATER MD

Provider Business Mailing Address
First Line	:	3801 WAKE FOREST RD STE 210
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27609-6864
Country	:	US
Telephone Number	:	919-787-7246
Fax Number	:	919-787-7247

Provider Business Practice Location Address
First Line	:	260 ROBESON ST
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28301-5573
Country	:	US
Telephone Number	:	910-984-8311
Fax Number	:	919-787-7247

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

Provider Enumeration Date	:	06/02/2020
Last Update Date	:	03/13/2026

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