Provider Demographics
NPI:1275526253
Name:WALLOP, JOHN DOUGLASS
Entity Type:Individual
Prefix:MR
First Name:JOHN DOUGLASS
Middle Name:
Last Name:WALLOP
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:DOUG
Other - Middle Name:
Other - Last Name:WALLOP
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2661 RIVA RD
Mailing Address - Street 2:BLDG 600, SUITE 601
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-7353
Mailing Address - Country:US
Mailing Address - Phone:410-266-6626
Mailing Address - Fax:410-266-3026
Practice Address - Street 1:2661 RIVA RD
Practice Address - Street 2:BLDG 600, SUITE 601
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-7353
Practice Address - Country:US
Practice Address - Phone:410-266-6626
Practice Address - Fax:410-266-3026
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2012-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD17006225100000X, 2251P0200X, 2251S0007X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD227912OtherMAMSI PROVIDER NUMBER
MD7947168OtherAETNA NON-HMO NUMBER
MD2621453OtherAETNA HMO NUMBER
MD53056502OtherBC REGION RENDERING #
MDKN59OtherBLUE CROSS LOCAL #
MDW0290002OtherBC FEDERAL, BLUE CHOICE #
MDKN59KM39Medicare ID - Type UnspecifiedMEDICARE IND. PROVIDER #
MD2621453OtherAETNA HMO NUMBER
MD17006Medicare UPIN