Provider Demographics
NPI:1275563397
Name:VAN DER WERF, WILLEM J (MD)
Entity Type:Individual
Prefix:
First Name:WILLEM
Middle Name:J
Last Name:VAN DER WERF
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 1:2218 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-1401
Mailing Address - Country:US
Mailing Address - Phone:602-252-2543
Mailing Address - Fax:602-252-3861
Practice Address - Street 1:2218 N 3RD ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-1401
Practice Address - Country:US
Practice Address - Phone:602-252-2543
Practice Address - Fax:602-252-3861
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5249271205174400000X
AZ49927204F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204F00000XAllopathic & Osteopathic PhysiciansTransplant Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
52492781200001OtherBLUE CROSS BLUE SHIELD
4658850OtherCIGNA
TPRA07781OtherMOLINA
WY119626000Medicaid
QM000006442OtherALTIUS
ID806894300Medicaid