Provider Demographics
NPI:1952410185
Name:VANDEWALLE, KATHLEEN ELAINE I (DO)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:ELAINE
Last Name:VANDEWALLE
Suffix:I
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1314 N. MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:SD
Mailing Address - Zip Code:57401-2700
Mailing Address - Country:US
Mailing Address - Phone:605-725-3136
Mailing Address - Fax:605-725-3137
Practice Address - Street 1:1314 NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:SD
Practice Address - Zip Code:57401-2700
Practice Address - Country:US
Practice Address - Phone:605-725-3136
Practice Address - Fax:605-725-3137
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1404207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD42419Medicare ID - Type Unspecified
D60792Medicare UPIN