Provider Demographics
NPI:1730419243
Name:WILLIAM VAN DER REIS MD INC
Entity type:Organization
Organization Name:WILLIAM VAN DER REIS MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:L
Authorized Official - Last Name:VAN DER REIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-661-2423
Mailing Address - Street 1:653 CAMINO DE LOS MARES
Mailing Address - Street 2:SUITE 109
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-2808
Mailing Address - Country:US
Mailing Address - Phone:949-661-2423
Mailing Address - Fax:949-661-9205
Practice Address - Street 1:653 CAMINO DE LOS MARES
Practice Address - Street 2:SUITE 109
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-2808
Practice Address - Country:US
Practice Address - Phone:949-661-2423
Practice Address - Fax:949-661-9205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-05
Last Update Date:2010-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG81476207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty