Provider Demographics
NPI:1710987391
Name:WALLACH, PETER MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:MICHAEL
Last Name:WALLACH
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 1:1480 N UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33071-6040
Mailing Address - Country:US
Mailing Address - Phone:954-753-1030
Mailing Address - Fax:954-753-1115
Practice Address - Street 1:1480 N UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33071-6040
Practice Address - Country:US
Practice Address - Phone:954-753-1030
Practice Address - Fax:954-753-1115
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2010-07-15
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-03-30
Provider Licenses
StateLicense IDTaxonomies
FLME0029164207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0008978OtherGHI PROVIDER ID
FL406073297OtherRR MEDICARE
FL0706177OtherAETNA ID
FL057349300Medicaid
FL4958275OtherCIGNA ID
FL0706177OtherAETNA ID
FL93398ZMedicare ID - Type UnspecifiedMEDICARE NUMBER