Provider Demographics
NPI:1760517288
Name:VAN DE WALLE, NAHEED ASAD (MD)
Entity Type:Individual
Prefix:DR
First Name:NAHEED
Middle Name:ASAD
Last Name:VAN DE WALLE
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 1:111 SALEM TPKE
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-7403
Mailing Address - Country:US
Mailing Address - Phone:860-972-5107
Mailing Address - Fax:
Practice Address - Street 1:111 SALEM TPKE
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-7403
Practice Address - Country:US
Practice Address - Phone:860-972-5107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY154841208100000X
CT64242208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00790496Medicaid
NY55247OtherHIP
NYP2728904OtherOXFORD
NY230152OtherWCB
NY0037004OtherGHI
NYA300100661OtherPTAN
NYA300100661OtherPTAN