Provider Demographics
NPI:1033121504
Name:MALLERICH, WALTON JUDE (DC)
Entity Type:Individual
Prefix:
First Name:WALTON
Middle Name:JUDE
Last Name:MALLERICH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1651 BILL OGDEN DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79936-5723
Mailing Address - Country:US
Mailing Address - Phone:915-857-5653
Mailing Address - Fax:
Practice Address - Street 1:10536 MONTWOOD DR STE A
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79935-2707
Practice Address - Country:US
Practice Address - Phone:915-203-5744
Practice Address - Fax:915-857-5653
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDC5931111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1207OtherCHIROPRACTIC LICENSE #
TXDC5931OtherCHIROPRACTIC LICENSE #
TX608161Medicare UPIN