Provider Demographics
NPI:1285672154
Name:WALLIS, JOSEPH J (DO)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:J
Last Name:WALLIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:600 MOUNT PLEASANT AVE
Mailing Address - Street 2:SUITE G
Mailing Address - City:DOVER
Mailing Address - State:NJ
Mailing Address - Zip Code:07801-1629
Mailing Address - Country:US
Mailing Address - Phone:973-989-9000
Mailing Address - Fax:973-989-8225
Practice Address - Street 1:600 MOUNT PLEASANT AVE
Practice Address - Street 2:SUITE G
Practice Address - City:DOVER
Practice Address - State:NJ
Practice Address - Zip Code:07801-1629
Practice Address - Country:US
Practice Address - Phone:973-989-9000
Practice Address - Fax:973-989-8225
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MB02488400207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ25MB02488400OtherSTATE LICENSE
NJ25MB02488400OtherSTATE LICENSE
D80324Medicare UPIN