Provider Demographics
NPI:1093711087
Name:VANDER WILT, DARLO G (DPM)
Entity Type:Individual
Prefix:
First Name:DARLO
Middle Name:G
Last Name:VANDER WILT
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:505-764-9210
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:505-764-9210
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2014-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM099213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMF8031Medicaid
NMF8031Medicaid