1417000852 NPI number — DR. LEWIS A VANOSDEL III MD

Table of content: DR. LEWIS A VANOSDEL III MD (NPI 1417000852)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417000852 NPI number — DR. LEWIS A VANOSDEL III MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VANOSDEL
Provider First Name:
LEWIS
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
III
Provider Credential Text:
MD
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:
1417000852
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/17/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11602 SW BREYMAN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97219-8400
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1033 SW 152ND ST
Provider Second Line Business Practice Location Address:
NAVOS SUNSTONE YOUTH RESIDENTIAL
Provider Business Practice Location Address City Name:
BURIEN
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98166
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-829-1121
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/19/2007

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: 2084P0802X , with the licence number:  9213117-1205 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0804X , with the licence number: G-33962 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0804X , with the licence number: MD00033116 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0800X , with the licence number: G33962 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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