Provider Demographics
NPI:1255383139
Name:WALLIS, DAVID (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:WALLIS
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:PO BOX 66657
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98166-0657
Mailing Address - Country:US
Mailing Address - Phone:424-437-4700
Mailing Address - Fax:424-437-8884
Practice Address - Street 1:520 N PROSPECT AVE STE 309
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-3043
Practice Address - Country:US
Practice Address - Phone:424-437-4700
Practice Address - Fax:424-437-8884
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA77627207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A776270OtherBLUE SHIELD
CAH91149Medicare UPIN
CAWA77627EMedicare ID - Type Unspecified