Healthcare Provider Details

I. General information

NPI: 1639190572
Provider Name (Legal Business Name): THOMAS J WALISER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2006
Last Update Date: 12/18/2023
Certification Date: 12/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1008 E MCDOWELL RD STE A
PHOENIX AZ
85006-2603
US

IV. Provider business mailing address

7330 N 16TH ST STE B101
PHOENIX AZ
85020-5274
US

V. Phone/Fax

Practice location:
  • Phone: 602-358-8588
  • Fax: 602-688-6991
Mailing address:
  • Phone: 602-358-8588
  • Fax: 602-688-6991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number39552
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: