Provider Demographics
NPI:1952401762
Name:WALLENS, DONALD E (MD)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:E
Last Name:WALLENS
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 1:2080 CENTURY PARK E STE 1406
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90067-2017
Mailing Address - Country:US
Mailing Address - Phone:310-556-2095
Mailing Address - Fax:310-556-2063
Practice Address - Street 1:2080 CENTURY PARK E STE 1406
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90067-2017
Practice Address - Country:US
Practice Address - Phone:310-556-2095
Practice Address - Fax:310-556-2063
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG126322084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA006126320Medicaid
CAA90215Medicare UPIN
CAAW4316546Medicare ID - Type Unspecified