Basic Information
| Provider Information | |||||||||
| NPI: | 1316975816 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VANDALSEM | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | DEPT LA 21555 | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911851555 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9497645570 | ||||||||
| FaxNumber: | 9492631639 | ||||||||
| Practice Location | |||||||||
| Address1: | ONE HOAG DRIVE | ||||||||
| Address2: | |||||||||
| City: | NEWPORT BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926634162 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9497645570 | ||||||||
| FaxNumber: | 9492631639 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2006 | ||||||||
| LastUpdateDate: | 12/12/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | G62331 | CA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 00G623310 | 01 | CA | BLUE SHIELD | OTHER | 00G623310 | 05 | CA | MEDICAID |