Provider Demographics
NPI:1184286643
Name:WALUS, RICHARD MARTIN
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:MARTIN
Last Name:WALUS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37555 SYCAMORE ST STE 7
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:CA
Mailing Address - Zip Code:94560-3939
Mailing Address - Country:US
Mailing Address - Phone:510-742-2472
Mailing Address - Fax:510-742-2462
Practice Address - Street 1:37555 SYCAMORE ST STE 7
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:CA
Practice Address - Zip Code:94560-3939
Practice Address - Country:US
Practice Address - Phone:510-742-2472
Practice Address - Fax:510-742-2462
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-05
Last Update Date:2019-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADME02439FMedicaid