Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207KA0200X | Allergist | G17502 | CA |
NPI | 1144331513 |
---|---|
Provider Name | Dr. William W Wallace |
First Address | San Diego, CA 92126-4427 |
Second Address | San Diego, CA 92126-4427 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 31/08/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00G175020 | (05) | CA |
A40097 | (02) | CA |