Provider Demographics
NPI:1952318461
Name:WALLMAN, BARRY JAY
Entity Type:Individual
Prefix:
First Name:BARRY
Middle Name:JAY
Last Name:WALLMAN
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 1:29525 CANWOOD ST
Mailing Address - Street 2:#305
Mailing Address - City:AGOURA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91301-4233
Mailing Address - Country:US
Mailing Address - Phone:818-707-7789
Mailing Address - Fax:818-707-7797
Practice Address - Street 1:29525 CANWOOD ST
Practice Address - Street 2:#305
Practice Address - City:AGOURA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91301-4233
Practice Address - Country:US
Practice Address - Phone:818-707-7789
Practice Address - Fax:818-707-7797
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2015-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG58527207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1952318461OtherNPI NUMBER INDIVIDUAL
CACB227753OtherPTAN
A93513Medicare UPIN
CA1952318461OtherNPI NUMBER INDIVIDUAL
A93513Medicare UPIN