Provider Demographics
NPI:1952468233
Name:WALLNER, PAUL ELLIOT (DO)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:ELLIOT
Last Name:WALLNER
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 1:140 FELLSWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MOORESTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08057-4015
Mailing Address - Country:US
Mailing Address - Phone:856-234-6336
Mailing Address - Fax:
Practice Address - Street 1:130 CARNIE BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-4521
Practice Address - Country:US
Practice Address - Phone:856-424-0003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB036183002085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology