Provider Demographics
NPI:1679591218
Name:VANTILBURG, CHRISTOPHER SCOTT (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:SCOTT
Last Name:VANTILBURG
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:PO BOX 1556
Mailing Address - Street 2:
Mailing Address - City:HOOD RIVER
Mailing Address - State:OR
Mailing Address - Zip Code:97031-0556
Mailing Address - Country:US
Mailing Address - Phone:541-490-2983
Mailing Address - Fax:
Practice Address - Street 1:3400 MAIN ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98663-2223
Practice Address - Country:US
Practice Address - Phone:360-514-7005
Practice Address - Fax:360-514-7075
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00036308207Q00000X
ORMD20269207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8233355Medicaid
AB18417Medicare ID - Type Unspecified
WA8233355Medicaid