Provider Demographics
NPI:1396773719
Name:VANDERHAL, ANDRE L (MD)
Entity type:Individual
Prefix:DR
First Name:ANDRE
Middle Name:L
Last Name:VANDERHAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10251 CRESTA DR
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064-3432
Mailing Address - Country:US
Mailing Address - Phone:310-600-1807
Mailing Address - Fax:
Practice Address - Street 1:15107 VANOWEN ST
Practice Address - Street 2:NICU
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-4542
Practice Address - Country:US
Practice Address - Phone:818-902-2978
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA371362080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF41931Medicare UPIN