Provider Demographics
NPI:1417000852
Name:VANOSDEL, LEWIS A III (MD)
Entity Type:Individual
Prefix:DR
First Name:LEWIS
Middle Name:A
Last Name:VANOSDEL
Suffix:III
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 1:11602 SW BREYMAN AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-8400
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1033 SW 152ND ST
Practice Address - Street 2:NAVOS SUNSTONE YOUTH RESIDENTIAL
Practice Address - City:BURIEN
Practice Address - State:WA
Practice Address - Zip Code:98166
Practice Address - Country:US
Practice Address - Phone:206-829-1121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9213117-12052084P0802X
CAG-339622084P0804X, 2084P0804X
WAMD000331162084P0804X
CAG339622084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry