Provider Demographics
NPI:1831228543
Name:WALLO, PHYLLIS B (MD)
Entity type:Individual
Prefix:MS
First Name:PHYLLIS
Middle Name:B
Last Name:WALLO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7611 MAPLE ST
Mailing Address - Street 2:SUITE A1
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70118-5068
Mailing Address - Country:US
Mailing Address - Phone:504-444-5640
Mailing Address - Fax:
Practice Address - Street 1:7611 MAPLE ST
Practice Address - Street 2:SUITE A1
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70118-5068
Practice Address - Country:US
Practice Address - Phone:504-444-5640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA0196362084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1380661Medicaid
LA55034Medicare ID - Type Unspecified
LA1380661Medicaid