Provider Demographics
NPI:1154465672
Name:WALLACH, JAMIE ELISE (MD)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:ELISE
Last Name:WALLACH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1332 PARK ST STE 202
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-4545
Mailing Address - Country:US
Mailing Address - Phone:510-523-3417
Mailing Address - Fax:510-521-1659
Practice Address - Street 1:1332 PARK ST STE 202
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-4545
Practice Address - Country:US
Practice Address - Phone:510-523-3417
Practice Address - Fax:510-521-1659
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG799032080B0002X, 208000000X, 2080B0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080B0002XAllopathic & Osteopathic PhysiciansPediatricsObesity Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1912186834Medicaid