Basic Information
| Provider Information | |||||||||
| NPI: | 1386724375 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JACQUELYN VANDER WALL MD. INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | OPTUMCARE MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3460 KATELLA AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ALAMITOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907202334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5625946599 | ||||||||
| FaxNumber: | 5625987116 | ||||||||
| Practice Location | |||||||||
| Address1: | 11 TECHNOLOGY DR | ||||||||
| Address2: | |||||||||
| City: | IRVINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926182302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9499233250 | ||||||||
| FaxNumber: | 8558125865 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2006 | ||||||||
| LastUpdateDate: | 04/26/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | VANDER WALL | ||||||||
| AuthorizedOfficialFirstName: | JACQUELYN | ||||||||
| AuthorizedOfficialMiddleName: | LEE | ||||||||
| AuthorizedOfficialTitleorPosition: | MD | ||||||||
| AuthorizedOfficialTelephone: | 5625946599 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | G065045 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 00G65045G | 05 | CA | MEDICAID | CB252872 | 01 | CA | MEDICARE | OTHER |