Provider Demographics
NPI:1710911078
Name:VAN DER REIS, WILLIAM L
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:L
Last Name:VAN DER REIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:653 CAMINO DE LOS MARES STE 109
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-2808
Mailing Address - Country:US
Mailing Address - Phone:949-661-2423
Mailing Address - Fax:949-661-9205
Practice Address - Street 1:653 CAMINO DE LOS MARES STE 109
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-2808
Practice Address - Country:US
Practice Address - Phone:949-661-2423
Practice Address - Fax:949-661-9205
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG81476174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF36456Medicare UPIN