Provider Demographics
NPI:1457557613
Name:WALLIN, BRETT S (MD)
Entity Type:Individual
Prefix:DR
First Name:BRETT
Middle Name:S
Last Name:WALLIN
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 1:368 E RIVERSIDE DR STE 3B
Mailing Address - Street 2:
Mailing Address - City:SAINT GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-7068
Mailing Address - Country:US
Mailing Address - Phone:435-656-3324
Mailing Address - Fax:435-656-3325
Practice Address - Street 1:368 E RIVERSIDE DR STE 3B
Practice Address - Street 2:
Practice Address - City:SAINT GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-7068
Practice Address - Country:US
Practice Address - Phone:435-656-3324
Practice Address - Fax:435-656-3325
Is Sole Proprietor?:No
Enumeration Date:2007-06-25
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ81245207R00000X
IN01068450A207R00000X
UT7984164-1205207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201004220Medicaid
IN201004220Medicaid