Provider Demographics
NPI:1225194210
Name:WALLEN, REGINALD M (MD)
Entity Type:Individual
Prefix:DR
First Name:REGINALD
Middle Name:M
Last Name:WALLEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2101 EAST JEFFERSON STREET
Mailing Address - Street 2:KAISER PERMANENTE, PPQA, 6 WEST, ATTN: THERESA BROOKS
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852
Mailing Address - Country:US
Mailing Address - Phone:301-816-6660
Mailing Address - Fax:301-816-6308
Practice Address - Street 1:6104 OLD BRANCH AVENUE
Practice Address - Street 2:KAISER PERMANENTE, PPQA, 6 WEST, ATTN THERESA BROOKS
Practice Address - City:TEMPLE HILLS
Practice Address - State:MD
Practice Address - Zip Code:20748-2518
Practice Address - Country:US
Practice Address - Phone:301-702-6100
Practice Address - Fax:301-702-6367
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MDD35317207Q00000X
VA0101044800207Q00000X
DCMD16350207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDC88963Medicare UPIN
MDK679H314Medicare ID - Type Unspecified