Provider Demographics
NPI:1740242452
Name:WALLENKAMPF, VICTOR (MD)
Entity Type:Individual
Prefix:
First Name:VICTOR
Middle Name:
Last Name:WALLENKAMPF
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 1:1726 SPRING HILL LANE
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:95524-1461
Mailing Address - Country:US
Mailing Address - Phone:707-822-6161
Mailing Address - Fax:
Practice Address - Street 1:2700 DOLBEER ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-4736
Practice Address - Country:US
Practice Address - Phone:707-269-4250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD23323207P00000X
CAG82276207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G822760Medicaid
CA00G822761Medicare ID - Type Unspecified
CAB16090Medicare UPIN