Provider Demographics
NPI:1023190220
Name:VANDER WAAL, STEVEN CRAIG (MD)
Entity Type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:CRAIG
Last Name:VANDER WAAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3619 HIGHWAY 101 N
Mailing Address - Street 2:
Mailing Address - City:GEARHART
Mailing Address - State:OR
Mailing Address - Zip Code:97138-4321
Mailing Address - Country:US
Mailing Address - Phone:503-738-3832
Mailing Address - Fax:503-738-3466
Practice Address - Street 1:3619 HIGHWAY 101 N
Practice Address - Street 2:
Practice Address - City:GEARHART
Practice Address - State:OR
Practice Address - Zip Code:97138-4321
Practice Address - Country:US
Practice Address - Phone:503-738-3832
Practice Address - Fax:503-738-3466
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2014-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR13959261QM2500X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORC91340Medicare UPIN
ORR0000BJBXVMedicare ID - Type Unspecified