1497789077 NPI number — DR. DAVID MICHAEL WANALISTA D.O.

Table of content: DR. DAVID MICHAEL WANALISTA D.O. (NPI 1497789077)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497789077 NPI number — DR. DAVID MICHAEL WANALISTA D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WANALISTA
Provider First Name:
DAVID
Provider Middle Name:
MICHAEL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1497789077
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/05/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9733 HEALTHWAY DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BERLIN
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21811
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-691-8444
Provider Business Mailing Address Fax Number:
856-691-8325

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10231 OLD OCEAN CITY BLVD
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
BERLIN
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21811
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-641-9482
Provider Business Practice Location Address Fax Number:
410-641-9516
Provider Enumeration Date:
07/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RR0500X , with the licence number:  25MB07794500 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 193571200 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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