Provider Demographics
NPI:1922033604
Name:FALLSTROM, ROBERT LEWIS (DO)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:LEWIS
Last Name:FALLSTROM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 S 14TH AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-3101
Mailing Address - Country:US
Mailing Address - Phone:509-426-2378
Mailing Address - Fax:509-426-2380
Practice Address - Street 1:5 S 14TH AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-3101
Practice Address - Country:US
Practice Address - Phone:509-426-2378
Practice Address - Fax:509-426-2380
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP0001389207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2047318Medicaid
WAF00323Medicare UPIN