Provider Demographics
NPI:1821794645
Name:TOMI LEE WALL MD PC
Entity Type:Organization
Organization Name:TOMI LEE WALL MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TOMI
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:WALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:925-348-4366
Mailing Address - Street 1:3300 WEBSTER ST STE 1106
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-3125
Mailing Address - Country:US
Mailing Address - Phone:510-763-2662
Mailing Address - Fax:
Practice Address - Street 1:3300 WEBSTER ST STE 1106
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3125
Practice Address - Country:US
Practice Address - Phone:510-763-2662
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-02
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1417947060OtherNPI - TYPE I