1013925007 NPI number — DR. MICHAEL F VANDEWALLE DC

Table of content: DR. MICHAEL F VANDEWALLE DC (NPI 1013925007)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013925007 NPI number — DR. MICHAEL F VANDEWALLE DC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VANDEWALLE
Provider First Name:
MICHAEL
Provider Middle Name:
F
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
VANDEWALLE
Provider Other First Name:
MIKE
Provider Other Middle Name:
F
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DC
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1013925007
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/02/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11824 JOLLYVILLE RD
Provider Second Line Business Mailing Address:
SUITE 500
Provider Business Mailing Address City Name:
AUSTIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78759-2322
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-343-0700
Provider Business Mailing Address Fax Number:
512-343-0775

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11824 JOLLYVILLE RD
Provider Second Line Business Practice Location Address:
SUITE 500
Provider Business Practice Location Address City Name:
AUSTIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78759-2322
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-343-0700
Provider Business Practice Location Address Fax Number:
512-343-0775
Provider Enumeration Date:
08/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  DC2771 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 111N00000X , with the licence number: 04589 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2771 . This is a "STATE LICENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: C06060612 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8P0221 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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