Provider Demographics
NPI:1134562739
Name:VANTASSEL, CRAIG JAMES (DO)
Entity type:Individual
Prefix:
First Name:CRAIG
Middle Name:JAMES
Last Name:VANTASSEL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3259 CATLIN AVE
Mailing Address - Street 2:
Mailing Address - City:QUANTICO
Mailing Address - State:VA
Mailing Address - Zip Code:22134-5109
Mailing Address - Country:US
Mailing Address - Phone:703-784-5541
Mailing Address - Fax:
Practice Address - Street 1:13 AREA BRANCH HEALTH CLINIC
Practice Address - Street 2:BUILDING 13127
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92058-5109
Practice Address - Country:US
Practice Address - Phone:760-763-0306
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-12
Last Update Date:2024-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1241207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine