Provider Demographics
NPI:1528035979
Name:WALLACH, ANDREW B (MD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:B
Last Name:WALLACH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 SAN PABLO AVE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:CA
Mailing Address - Zip Code:94706-1103
Mailing Address - Country:US
Mailing Address - Phone:510-204-8130
Mailing Address - Fax:
Practice Address - Street 1:500 SAN PABLO AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:ALBANY
Practice Address - State:CA
Practice Address - Zip Code:94706-1127
Practice Address - Country:US
Practice Address - Phone:510-204-8130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00G41883207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G41883Medicare ID - Type UnspecifiedINDIVIDUAL STATE LICENSE