Provider Demographics
NPI:1093737199
Name:VAN TASSEL, EDWARD L (DO)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:L
Last Name:VAN TASSEL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 BRYANT WILLIAMS DRIVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601-1120
Mailing Address - Country:US
Mailing Address - Phone:541-884-7746
Mailing Address - Fax:541-884-0848
Practice Address - Street 1:2200 BRYANT WILLIAMS DRIVE
Practice Address - Street 2:SUITE 1
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-1120
Practice Address - Country:US
Practice Address - Phone:541-884-7746
Practice Address - Fax:541-884-0848
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO25890207X00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP00464722OtherRAIL ROAD MEDICARE
OR213618Medicaid
CAXPY145960OtherMEDI-CAL
ORP00419803OtherRAIL ROAD MEDICARE
OR20889454297601OtherTRICARE
OR820591000OtherBLUE CROSS
OR820591000OtherBLUE CROSS
ORR137469Medicare PIN
OR820591000OtherBLUE CROSS
ORP00464722OtherRAIL ROAD MEDICARE