Healthcare Provider Details

I. General information

NPI: 1114169760
Provider Name (Legal Business Name): CAROLINE LEE WALLNER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2009
Last Update Date: 01/08/2020
Certification Date: 01/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2625 W ALAMEDA AVE STE 310
BURBANK CA
91505-4819
US

IV. Provider business mailing address

5767 W CENTURY BLVD SUITE 400
LOS ANGELES CA
90045-5631
US

V. Phone/Fax

Practice location:
  • Phone: 310-794-7700
  • Fax: 818-260-8718
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License NumberA113187
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberA113187
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: