Healthcare Provider Details

I. General information

NPI: 1710927025
Provider Name (Legal Business Name): JAMES IRA WALLSTROM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1809 VERDUGO BLVD STE 350
GLENDALE CA
91208-1476
US

IV. Provider business mailing address

50 BELLEFONTAINE ST SUITE 205
PASADENA CA
91105-3132
US

V. Phone/Fax

Practice location:
  • Phone: 818-790-0914
  • Fax: 818-790-2816
Mailing address:
  • Phone: 626-792-4115
  • Fax: 626-792-3103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberG74317
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: