Provider Demographics
NPI:1114929403
Name:GAUNTNER, WALLACE C (MD)
Entity Type:Individual
Prefix:
First Name:WALLACE
Middle Name:C
Last Name:GAUNTNER
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 1:824 CALIFORNIA AVE
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15202-2706
Mailing Address - Country:US
Mailing Address - Phone:412-766-3232
Mailing Address - Fax:412-766-4320
Practice Address - Street 1:824 CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15202-2706
Practice Address - Country:US
Practice Address - Phone:412-766-3232
Practice Address - Fax:412-766-4320
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35068280207RN0300X
PAMD019281E207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0070822000Medicaid
OH0642228Medicaid
110025252OtherRAILROAD MEDICARE
PA000793311Medicaid
WV0070822000Medicaid
OH0642228Medicaid
PA068201HYPMedicare PIN