Provider Demographics
NPI:1609872795
Name:VANDEWALL, JAMES CRAIG (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:CRAIG
Last Name:VANDEWALL
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 1:415 N 8TH ST
Mailing Address - Street 2:P.O. BOX 1208
Mailing Address - City:OLEAN
Mailing Address - State:NY
Mailing Address - Zip Code:14760-6208
Mailing Address - Country:US
Mailing Address - Phone:716-372-9399
Mailing Address - Fax:716-373-5530
Practice Address - Street 1:415 N 8TH ST
Practice Address - Street 2:
Practice Address - City:OLEAN
Practice Address - State:NY
Practice Address - Zip Code:14760-2237
Practice Address - Country:US
Practice Address - Phone:716-372-9399
Practice Address - Fax:716-373-5530
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-23
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY195467207RR0500X
NY195467-1207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP00079354OtherRR MEDICARE
NY01482237Medicaid
NY01482237Medicaid
NYRA0594Medicare PIN