Healthcare Provider Details

I. General information

NPI: 1982916037
Provider Name (Legal Business Name): DONALD E WALLENS MD A MEDICAL CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2010
Last Update Date: 09/24/2020
Certification Date: 09/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2080 CENTURY PARK E STE 1406
LOS ANGELES CA
90067-2017
US

IV. Provider business mailing address

2080 CENTURY PARK E STE 1406
LOS ANGELES CA
90067-2017
US

V. Phone/Fax

Practice location:
  • Phone: 310-556-2095
  • Fax: 310-556-2063
Mailing address:
  • Phone: 310-556-2095
  • Fax: 310-556-2063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberG12632
License Number StateCA

VIII. Authorized Official

Name: SHARON SINDELL
Title or Position: ASSISTANT
Credential:
Phone: 310-556-2095