Provider Demographics
NPI:1700802964
Name:WALLSTROM, TOR ERIK WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:TOR ERIK
Middle Name:WILLIAM
Last Name:WALLSTROM
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 1:1394 W 16TH ST
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-4430
Mailing Address - Country:US
Mailing Address - Phone:928-539-0055
Mailing Address - Fax:928-539-0053
Practice Address - Street 1:1394 W 16TH ST
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-4430
Practice Address - Country:US
Practice Address - Phone:928-539-0055
Practice Address - Fax:928-539-0053
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ25545207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ469024001Medicaid
AZH05396Medicare UPIN
AZ72718Medicare ID - Type Unspecified