Provider Demographics
NPI:1497789077
Name:WANALISTA, DAVID MICHAEL (DO)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:MICHAEL
Last Name:WANALISTA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1206 W SHERMAN AVE
Mailing Address - Street 2:BUILDING 1
Mailing Address - City:VINELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:08360-6916
Mailing Address - Country:US
Mailing Address - Phone:856-691-8444
Mailing Address - Fax:856-691-8325
Practice Address - Street 1:1206 W SHERMAN AVE
Practice Address - Street 2:BUILDING 1
Practice Address - City:VINELAND
Practice Address - State:NJ
Practice Address - Zip Code:08360-6916
Practice Address - Country:US
Practice Address - Phone:856-691-8444
Practice Address - Fax:856-691-8325
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB07794500207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1965312Medicaid
NJ086324Medicare ID - Type Unspecified
NJ1965312Medicaid