Provider Demographics
NPI:1326044751
Name:VAN DE WYNGAERDE, GEORGE A (MD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:A
Last Name:VAN DE WYNGAERDE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:444 W OSBORN RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-3814
Mailing Address - Country:US
Mailing Address - Phone:602-230-1400
Mailing Address - Fax:602-230-7676
Practice Address - Street 1:444 W OSBORN RD
Practice Address - Street 2:SUITE 200
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-3814
Practice Address - Country:US
Practice Address - Phone:602-230-1400
Practice Address - Fax:602-230-7676
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ6074207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
D00478Medicare UPIN