Provider Demographics
NPI:1710924451
Name:WALLEN, HERSCHEL D (MD)
Entity Type:Individual
Prefix:DR
First Name:HERSCHEL
Middle Name:D
Last Name:WALLEN
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 1189
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-1189
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:441 NW ELKS DR STE 100
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-3744
Practice Address - Country:US
Practice Address - Phone:541-768-4950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00040124207RX0202X
ORMD153740207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500631243Medicaid
WA8455354Medicaid
WA8883097OtherMEDICARE - KITSAP CO
OR500631243Medicaid
WA8860245Medicare ID - Type UnspecifiedUWP
WA8874968Medicare PIN
OR157627Medicare PIN