Individual
DR. MA THERESA L. VANDEN BERG
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
1718 E KESSLER BLVD, LONGVIEW, WA 98632-1842
(360) 747-5800
(360) 575-3846
Mailing address
PO BOX 3002, LONGVIEW, WA 98632-0302
(360) 747-5800
(360) 575-3846
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
4301089956
MI
207Q00000X
Family Medicine Physician
Primary
MD60120609
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0263926
L & I /CRIME VICTIMS
WA
05
—
2008004
—
WA
05
—
500624616
—
OR
Enumeration date
07/27/2007
Last updated
07/30/2012
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