1720320666 NPI number — DR. ANNE RANDOLPH VAN DE WATER M.D.

Table of content: DR. ANNE RANDOLPH VAN DE WATER M.D. (NPI 1720320666)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720320666 NPI number — DR. ANNE RANDOLPH VAN DE WATER M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VAN DE WATER
Provider First Name:
ANNE
Provider Middle Name:
RANDOLPH
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

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:
1720320666
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/18/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6297
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAGUNA NIGUEL
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92607-6297
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-487-7262
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
31096 FLYING CLOUD DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAGUNA NIGUEL
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92677-2714
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-487-7262
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/18/2013

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: 207V00000X , with the licence number:  G38375 , 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)





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