Provider Demographics
NPI:1972709376
Name:THOMAS L. VANDER LAAN, M.D., AMC
Entity Type:Organization
Organization Name:THOMAS L. VANDER LAAN, M.D., AMC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR-PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:L
Authorized Official - Last Name:VANDER LAAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-793-4136
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-22
Last Update Date:2013-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG44443174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW1289OtherMEDICARE PTAN
CA00G444430Medicaid
CA00G444430Medicaid
CAE55955Medicare UPIN
CAW1289Medicare ID - Type UnspecifiedTYPE 2
CAW1289OtherMEDICARE PTAN