1639174063 NPI number — MR. THOMAS L VANDER LAAN M.D.

Table of content: MR. THOMAS L VANDER LAAN M.D. (NPI 1639174063)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639174063 NPI number — MR. THOMAS L VANDER LAAN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VANDER LAAN
Provider First Name:
THOMAS
Provider Middle Name:
L
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639174063
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/01/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/17/2006
NPI Reactivation Date:
03/31/2006

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
50 BELLEFONTAINE ST
Provider Second Line Business Mailing Address:
STE 303
Provider Business Mailing Address City Name:
PASADENA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91105-3132
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
626-793-4136
Provider Business Mailing Address Fax Number:
626-793-8279

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
50 BELLEFONTAINE ST
Provider Second Line Business Practice Location Address:
STE 303
Provider Business Practice Location Address City Name:
PASADENA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91105-3132
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
626-793-4136
Provider Business Practice Location Address Fax Number:
626-793-8279
Provider Enumeration Date:
06/13/2005

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: 174400000X , with the licence number:  G44443 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: G44443 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2086S0102X , with the licence number: G44443 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 00G444430 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: W1289 . This is a "MEDICARE PTAN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".