Provider Demographics
NPI:1942567235
Name:WALLMAN, JOHN (DC)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:WALLMAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2805 VETERANS MEMORIAL HWY
Mailing Address - Street 2:STE 8
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-7680
Mailing Address - Country:US
Mailing Address - Phone:631-440-7008
Mailing Address - Fax:
Practice Address - Street 1:2805 VETERANS MEMORIAL HWY
Practice Address - Street 2:STE 8
Practice Address - City:RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-7680
Practice Address - Country:US
Practice Address - Phone:631-440-7008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-12
Last Update Date:2016-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2887111NN1001X
MA1329111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN1001XChiropractic ProvidersChiropractorNutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY35962OtherBC/BS
NY2887OtherCHIROPRACTIC LICENSE
MA1329OtherMASSACHUSETTS LICENSE
MA625080OtherCIGNA PIN
MA798258OtherTUFTS PROVIDER #
NY227986OtherNEW YORK WORKERS COMPENSATION
NY2887OtherCHIROPRACTIC LICENSE