Provider Demographics
NPI:1881989085
Name:JAMES I. WALLSTROM, M.D., INC.
Entity type:Organization
Organization Name:JAMES I. WALLSTROM, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:I
Authorized Official - Last Name:WALLSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-792-4115
Mailing Address - Street 1:50 BELLEFONTAINE ST STE 205
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-3132
Mailing Address - Country:US
Mailing Address - Phone:626-792-4115
Mailing Address - Fax:626-792-3103
Practice Address - Street 1:50 BELLEFONTAINE ST STE 205
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-3132
Practice Address - Country:US
Practice Address - Phone:626-792-4115
Practice Address - Fax:626-792-3103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-15
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG74317207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF41152Medicare UPIN