Provider Demographics
NPI:1982741021
Name:WALLACH, ADAM GREGORY (MD)
Entity Type:Individual
Prefix:DR
First Name:ADAM
Middle Name:GREGORY
Last Name:WALLACH
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 1:400 EL CERRO BLVD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:DANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94526-1731
Mailing Address - Country:US
Mailing Address - Phone:925-837-8848
Mailing Address - Fax:925-837-4808
Practice Address - Street 1:400 EL CERRO BLVD
Practice Address - Street 2:SUITE 204
Practice Address - City:DANVILLE
Practice Address - State:CA
Practice Address - Zip Code:94526-1731
Practice Address - Country:US
Practice Address - Phone:925-837-8848
Practice Address - Fax:925-837-4808
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG85998207N00000X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG48199Medicare UPIN
CA00G859980Medicare ID - Type UnspecifiedMEDICARE PART B