Provider Demographics
NPI:1093764078
Name:WALLIN, BECKY L (MD)
Entity Type:Individual
Prefix:DR
First Name:BECKY
Middle Name:L
Last Name:WALLIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:BECKY
Other - Middle Name:L
Other - Last Name:MCCALLA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2350 W EL CAMINO REAL
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94040-6201
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2400 SAMARITAN DR
Practice Address - Street 2:SUITE 203
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95124-3910
Practice Address - Country:US
Practice Address - Phone:408-879-9941
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA55243207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA55243OtherSTATE LICENSE
CAP00118398OtherMEDICARE RAILROAD
CA05D1002837OtherCLIA
CABW4743185OtherDEA NUMBER
CABW4743185OtherDEA NUMBER
CAA55243OtherSTATE LICENSE