Provider Demographics
NPI:1780776377
Name:WALLENDJACK, JOHN CHARLES (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:CHARLES
Last Name:WALLENDJACK
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 1:127 HILLYMEDE CIRCLE
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17111-4911
Mailing Address - Country:US
Mailing Address - Phone:717-566-9881
Mailing Address - Fax:
Practice Address - Street 1:3721 TECPORT DRIVE
Practice Address - Street 2:HEALTH AMERICA
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17106-7103
Practice Address - Country:US
Practice Address - Phone:717-540-6774
Practice Address - Fax:717-671-2459
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMDO19773E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine