Provider Demographics
NPI:1013020924
Name:GARY S WALLACH DPM PA
Entity Type:Organization
Organization Name:GARY S WALLACH DPM PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:S
Authorized Official - Last Name:WALLACH
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:954-561-3338
Mailing Address - Street 1:2737 E OAKLAND PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33306-1641
Mailing Address - Country:US
Mailing Address - Phone:954-561-3338
Mailing Address - Fax:954-566-3051
Practice Address - Street 1:2737 E OAKLAND PARK BLVD
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33306-1641
Practice Address - Country:US
Practice Address - Phone:954-561-3338
Practice Address - Fax:954-566-3051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL041067500Medicaid
FLDN9665OtherRAILROAD MEDICARE
FLK7141Medicare ID - Type UnspecifiedCORP #
FL041067500Medicaid
FL1241950001Medicare NSC