Provider Demographics
NPI:1487278875
Name:VAN DE WATER, TREVOR DOUGLAS (MD)
Entity type:Individual
Prefix:DR
First Name:TREVOR
Middle Name:DOUGLAS
Last Name:VAN DE WATER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3801 WAKE FOREST RD STE 210
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-6864
Mailing Address - Country:US
Mailing Address - Phone:919-787-7246
Mailing Address - Fax:919-787-7247
Practice Address - Street 1:260 ROBESON ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28301-5573
Practice Address - Country:US
Practice Address - Phone:910-984-8311
Practice Address - Fax:919-787-7247
Is Sole Proprietor?:No
Enumeration Date:2020-06-02
Last Update Date:2025-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11977207L00000X
NC2025-01885208100000X
390200000X
MDD0099403207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program