Provider Demographics
NPI:1689674905
Name:WALLENS, WILLIAM TODD (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:TODD
Last Name:WALLENS
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 1:3754 MILITARY RD
Mailing Address - Street 2:
Mailing Address - City:NIAGARA FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:14305-3517
Mailing Address - Country:US
Mailing Address - Phone:716-298-4330
Mailing Address - Fax:
Practice Address - Street 1:3754 MILITARY RD
Practice Address - Street 2:
Practice Address - City:NIAGARA FALLS
Practice Address - State:NY
Practice Address - Zip Code:14305-3517
Practice Address - Country:US
Practice Address - Phone:716-298-4330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY116615173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY116615OtherMEDICAL LICENSE #
NY00615509Medicaid
NY00615509Medicaid
NY116615OtherMEDICAL LICENSE #
NY072401Medicare ID - Type UnspecifiedMEDICARE ID #