Provider Demographics
NPI:1255309720
Name:WALLISA, ERIC D (MD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:D
Last Name:WALLISA
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 1:5955 S EMERSON AVE
Mailing Address - Street 2:100
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46237-2525
Mailing Address - Country:US
Mailing Address - Phone:317-789-9600
Mailing Address - Fax:317-789-0600
Practice Address - Street 1:5955 S EMERSON AVE
Practice Address - Street 2:100
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-2525
Practice Address - Country:US
Practice Address - Phone:317-789-9600
Practice Address - Fax:317-789-0600
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-10
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01054688A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN01054688AOtherSTATE MEDICAL LICENSE
IN01054688BOtherSTATE CSR
IN01054688BOtherSTATE CSR
H51074Medicare UPIN
219130BMedicare ID - Type Unspecified