Organization
JACQUELYN VANDER WALL MD. INC
Active
Other names
OptumCare Medical Group
Organization subpart
No
Provider details
NPI number
Authorized official
JACQUELYN LEE VANDER WALL M.D. (MD)
(562) 594-6599
Entity
Organization
Contact information
Practice address
11 TECHNOLOGY DR, IRVINE, CA 92618-2302
(949) 923-3250
(855) 812-5865
Mailing address
3460 KATELLA AVE, LOS ALAMITOS, CA 90720-2334
(562) 594-6599
(562) 598-7116
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
G065045
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00G65045G
—
CA
01
—
CB252872
MEDICARE
CA
Enumeration date
10/16/2006
Last updated
04/26/2016
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