Provider Demographics
NPI:1720668551
Name:WALLACH, WILLIAM J
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:J
Last Name:WALLACH
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 1:12901 BRUCE B DOWNS BLVD UNIT 715
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612-4742
Mailing Address - Country:US
Mailing Address - Phone:813-396-0075
Mailing Address - Fax:
Practice Address - Street 1:12901 BRUCE B DOWNS BLVD UNIT 715
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-4799
Practice Address - Country:US
Practice Address - Phone:813-396-9459
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-14
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program