Provider Demographics
NPI:1629009055
Name:MARK S. WALLEN, D.P.M., INC.
Entity Type:Organization
Organization Name:MARK S. WALLEN, D.P.M., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:S
Authorized Official - Last Name:WALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:310-828-0122
Mailing Address - Street 1:2001 SANTA MONICA BLVD
Mailing Address - Street 2:1190 W
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2102
Mailing Address - Country:US
Mailing Address - Phone:310-828-0122
Mailing Address - Fax:310-828-4463
Practice Address - Street 1:2001 SANTA MONICA BLVD
Practice Address - Street 2:1190 W
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2102
Practice Address - Country:US
Practice Address - Phone:310-828-0122
Practice Address - Fax:310-828-4463
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2009-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE 3104213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty