Provider Demographics
NPI:1881668085
Name:WALLIN, GENE AMBROSE (MD)
Entity Type:Individual
Prefix:DR
First Name:GENE
Middle Name:AMBROSE
Last Name:WALLIN
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 1:1118 TWO MILE CIR W
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28405-4125
Mailing Address - Country:US
Mailing Address - Phone:910-509-1784
Mailing Address - Fax:910-509-1784
Practice Address - Street 1:100 BREWSTER BLVD
Practice Address - Street 2:OCCUPATIONAL HEALTH CLINIC-BLDG 65
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28547-2538
Practice Address - Country:US
Practice Address - Phone:910-451-5707
Practice Address - Fax:910-451-3766
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC15347207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine