Provider Demographics
NPI:1710927025
Name:WALLSTROM, JAMES IRA (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:IRA
Last Name:WALLSTROM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:50 BELLEFONTAINE ST
Mailing Address - Street 2:SUITE 205
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-3132
Mailing Address - Country:US
Mailing Address - Phone:626-792-4115
Mailing Address - Fax:626-792-3103
Practice Address - Street 1:50 BELLEFONTAINE ST
Practice Address - Street 2:SUITE 205
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-3132
Practice Address - Country:US
Practice Address - Phone:626-792-4115
Practice Address - Fax:626-792-3103
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-07
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG74317207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F41152Medicare UPIN
W10572Medicare PIN