Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207KA0200X | Allergist | R2F17 | MO |
NPI | 1386833358 |
---|---|
Provider Name | Dr. Mark Lewis Vandewalker |
First Address | Columbia, MO 65203-6804 |
Second Address | Columbia, MO 65203-6804 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/10/2007 |
Last Update Date | 16/10/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
E38022 | (02) | MO |