Provider Demographics
NPI:1417947060
Name:WALL, TOMI LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:TOMI
Middle Name:LEE
Last Name:WALL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TOMI
Other - Middle Name:LEE
Other - Last Name:PANDOLFINO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3300 WEBSTER ST STE 1106
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-3125
Mailing Address - Country:US
Mailing Address - Phone:510-763-2662
Mailing Address - Fax:
Practice Address - Street 1:3300 WEBSTER ST
Practice Address - Street 2:SUITE 1106
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3117
Practice Address - Country:US
Practice Address - Phone:510-763-2662
Practice Address - Fax:510-601-0750
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-25
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA97586207NS0135X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA462225OtherTUFTS HEALTH PLAN
MAJ29028OtherBCBS MA
H24311Medicare UPIN