MEDICARE: STEVEN B WALLACH DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	2113	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1376660241
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STEVEN B WALLACH DO

Provider Business Mailing Address
First Line	:	3005 W INA RD
Second Line	:	SUITE 123
City	:	TUCSON
State	:	AZ
Zip	:	85741-2107
Country	:	US
Telephone Number	:	520-575-9110
Fax Number	:	520-575-8033

Provider Business Practice Location Address
First Line	:	3005 W INA RD
Second Line	:	SUITE 123
City	:	TUCSON
State	:	AZ
Zip	:	85741-2107
Country	:	US
Telephone Number	:	520-575-9110
Fax Number	:	520-575-8033

Authorized Official
Title or Position	:	SOLE PROPRIETOR
Name	:	STEVEN B WALLACH
Credential	:	DO
Telephone Number	:	520-575-9110

Provider Enumeration Date	:	03/23/2007
Last Update Date	:	08/22/2020

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