Provider Demographics
NPI:1164601449
Name:WALI, AUTAR KRISTEN (MD)
Entity Type:Individual
Prefix:
First Name:AUTAR
Middle Name:KRISTEN
Last Name:WALI
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 1:155 W WILLOW ST
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91768-1829
Mailing Address - Country:US
Mailing Address - Phone:909-865-2626
Mailing Address - Fax:909-865-2010
Practice Address - Street 1:155 W WILLOW ST
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91768-1829
Practice Address - Country:US
Practice Address - Phone:909-865-2626
Practice Address - Fax:909-865-2010
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-02
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA32290208600000X, 208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A322900Medicaid
CAGR0081880Medicaid
CAGR0081880Medicaid
CAWA32290CMedicare PIN