Provider Demographics
NPI:1073752127
Name:DARLO G VANDER WILT DPM
Entity Type:Organization
Organization Name:DARLO G VANDER WILT DPM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DARLO
Authorized Official - Middle Name:
Authorized Official - Last Name:VANDER WILT
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:505-843-6464
Mailing Address - Street 1:718 LOMAS BLVD NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-2073
Mailing Address - Country:US
Mailing Address - Phone:505-843-6464
Mailing Address - Fax:
Practice Address - Street 1:718 LOMAS BLVD NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2073
Practice Address - Country:US
Practice Address - Phone:505-843-6464
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-12
Last Update Date:2009-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM099213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM0529200002Medicare NSC
=========Medicare PIN