Provider Demographics
NPI:1699807792
Name:VANDER WALL, JACQUELYN LEE (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:LEE
Last Name:VANDER WALL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3460 KATELLA AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-2334
Mailing Address - Country:US
Mailing Address - Phone:562-594-6599
Mailing Address - Fax:562-598-7116
Practice Address - Street 1:11 TECHNOLOGY DR
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-2302
Practice Address - Country:US
Practice Address - Phone:949-923-3250
Practice Address - Fax:855-812-5865
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2017-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG065045207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G65045GMedicaid
CA110235790Medicare ID - Type Unspecified
CACB252872Medicare PIN
CA00G65045GMedicaid
CAW18164Medicare ID - Type Unspecified
CAWG65045GMedicare ID - Type Unspecified