Provider Demographics
NPI:1538115431
Name:WALLACH, PERRY (MD)
Entity Type:Individual
Prefix:DR
First Name:PERRY
Middle Name:
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:PO BOX 9477
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75711-9477
Mailing Address - Country:US
Mailing Address - Phone:903-594-2450
Mailing Address - Fax:903-509-0493
Practice Address - Street 1:1000 E 5TH ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-3346
Practice Address - Country:US
Practice Address - Phone:903-596-3500
Practice Address - Fax:903-596-3536
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2014-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM3420207R00000X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00326295OtherRAILROAD MEDICARE
TX8S6187OtherBLUE CROSS
TX181008701Medicaid
TXP00326295Medicare PIN
TX181008701Medicaid
TX8S6187OtherBLUE CROSS