1285672154 NPI number — DR. JOSEPH J WALLIS DO

Table of content: DR. JOSEPH J WALLIS DO (NPI 1285672154)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285672154 NPI number — DR. JOSEPH J WALLIS DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALLIS
Provider First Name:
JOSEPH
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1285672154
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/23/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
600 MOUNT PLEASANT AVE
Provider Second Line Business Mailing Address:
SUITE G
Provider Business Mailing Address City Name:
DOVER
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07801-1629
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-989-9000
Provider Business Mailing Address Fax Number:
973-989-8225

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
600 MOUNT PLEASANT AVE
Provider Second Line Business Practice Location Address:
SUITE G
Provider Business Practice Location Address City Name:
DOVER
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07801-1629
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-989-9000
Provider Business Practice Location Address Fax Number:
973-989-8225
Provider Enumeration Date:
06/03/2006

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: 207V00000X , with the licence number:  25MB02488400 , 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: 25MB02488400 . This is a "STATE LICENSE" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com