Provider Demographics
NPI:1013925007
Name:VANDEWALLE, MICHAEL F (DC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:F
Last Name:VANDEWALLE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:MIKE
Other - Middle Name:F
Other - Last Name:VANDEWALLE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC
Mailing Address - Street 1:11824 JOLLYVILLE RD
Mailing Address - Street 2:SUITE 500
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-2322
Mailing Address - Country:US
Mailing Address - Phone:512-343-0700
Mailing Address - Fax:512-343-0775
Practice Address - Street 1:11824 JOLLYVILLE RD
Practice Address - Street 2:SUITE 500
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-2322
Practice Address - Country:US
Practice Address - Phone:512-343-0700
Practice Address - Fax:512-343-0775
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDC2771111N00000X
IA04589111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2771OtherSTATE LICENSE
TXC06060612Medicaid
TX8P0221OtherBCBS
T16396Medicare UPIN
TX8F23512Medicare PIN
TX535923ZNXDMedicare PIN