Provider Demographics
NPI:1356903652
Name:WALLIS, CHRISTOPHER JAMES DERRICK (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:JAMES DERRICK
Last Name:WALLIS
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:719 THOMPSON LN STE 30330
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37204-4701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3601 THE VANDERBILT CLINIC
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37232-0001
Practice Address - Country:US
Practice Address - Phone:615-936-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-08
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN58513208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology