Provider Demographics
NPI:1063653061
Name:MENDELSON, WALLACE B (MD)
Entity Type:Individual
Prefix:DR
First Name:WALLACE
Middle Name:B
Last Name:MENDELSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10869 N SCOTTSDALE RD
Mailing Address - Street 2:#103-317
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85254-5280
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 E. APACHE ST.
Practice Address - Street 2:REMUDA RANCH
Practice Address - City:WICKENBURG
Practice Address - State:AZ
Practice Address - Zip Code:85390
Practice Address - Country:US
Practice Address - Phone:831-287-0518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-20
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC350902084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry