Provider Demographics
NPI:1376660241
Name:STEVEN B WALLACH DO
Entity Type:Organization
Organization Name:STEVEN B WALLACH DO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:B
Authorized Official - Last Name:WALLACH
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:520-575-9110
Mailing Address - Street 1:3005 W INA RD
Mailing Address - Street 2:SUITE 123
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85741-2107
Mailing Address - Country:US
Mailing Address - Phone:520-575-9110
Mailing Address - Fax:520-575-8033
Practice Address - Street 1:3005 W INA RD
Practice Address - Street 2:SUITE 123
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85741-2107
Practice Address - Country:US
Practice Address - Phone:520-575-9110
Practice Address - Fax:520-575-8033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2113207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ260703Medicaid
AZ260703Medicaid