Provider Demographics
NPI:1639174063
Name:VANDER LAAN, THOMAS L (MD)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:L
Last Name:VANDER LAAN
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 1:50 BELLEFONTAINE ST
Mailing Address - Street 2:STE 303
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-3132
Mailing Address - Country:US
Mailing Address - Phone:626-793-4136
Mailing Address - Fax:626-793-8279
Practice Address - Street 1:50 BELLEFONTAINE ST
Practice Address - Street 2:STE 303
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-3132
Practice Address - Country:US
Practice Address - Phone:626-793-4136
Practice Address - Fax:626-793-8279
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-13
Last Update Date:2013-04-01
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-03-31
Provider Licenses
StateLicense IDTaxonomies
CAG44443174400000X, 208600000X, 2086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G444430Medicaid
CAW1289OtherMEDICARE PTAN
CAWG44443BMedicare PIN
CAW1289OtherMEDICARE PTAN
CAW1289Medicare ID - Type Unspecified
CAWG44443BMedicare ID - Type UnspecifiedPPIN