Provider Demographics
NPI:1386724375
Name:JACQUELYN VANDER WALL MD. INC
Entity type:Organization
Organization Name:JACQUELYN VANDER WALL MD. INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELYN
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:VANDER WALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-594-6599
Mailing Address - Street 1:3460 KATELLA AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-2334
Mailing Address - Country:US
Mailing Address - Phone:562-594-6599
Mailing Address - Fax:562-598-7116
Practice Address - Street 1:11 TECHNOLOGY DR
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-2302
Practice Address - Country:US
Practice Address - Phone:949-923-3250
Practice Address - Fax:855-812-5865
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG065045174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G65045GMedicaid
CACB252872OtherMEDICARE
CAW18164Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER
CACB252872OtherMEDICARE
CAWG65045GMedicare ID - Type UnspecifiedINDIVIDUAL MEDICARE NUMBE