Healthcare Provider Details

I. General information

NPI: 1285696203
Provider Name (Legal Business Name): ROBERT JOSEPH WALLERSTEIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 05/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 E HUNTINGTON DR
MONROVIA CA
91016
US

IV. Provider business mailing address

16557 MARCHMONT DR
LOS GATOS CA
95032-5606
US

V. Phone/Fax

Practice location:
  • Phone: 626-471-7455
  • Fax:
Mailing address:
  • Phone: 408-335-8449
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License NumberG88350
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG88350
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: