Provider Demographics
NPI:1639190572
Name:WALISER, THOMAS J (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:J
Last Name:WALISER
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 1:7330 N 16TH ST STE B101
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-5274
Mailing Address - Country:US
Mailing Address - Phone:602-358-8588
Mailing Address - Fax:602-688-6991
Practice Address - Street 1:1008 E MCDOWELL RD STE A
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2603
Practice Address - Country:US
Practice Address - Phone:602-358-8588
Practice Address - Fax:602-688-6991
Is Sole Proprietor?:No
Enumeration Date:2006-07-23
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO39552207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO98103776OtherMEDICAID PRACTICE NUMBER
CO348308OtherMEDICARE GROUP NUMBER
CO810211OtherMEDICARE GROUP PTAN
COC810211OtherMEDICARE GROUP NUMBER
CO18335535Medicaid
CO51250331OtherMEDICAID GROUP NUMBER
CO807574Medicare PIN
COC810211OtherMEDICARE GROUP NUMBER
CO348308OtherMEDICARE GROUP NUMBER