Healthcare Provider Details

I. General information

NPI: 1417947060
Provider Name (Legal Business Name): TOMI LEE WALL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TOMI LEE PANDOLFINO MD

II. Dates (important events)

Enumeration Date: 10/25/2005
Last Update Date: 07/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 WEBSTER ST SUITE 1106
OAKLAND CA
94609-3117
US

IV. Provider business mailing address

3300 WEBSTER ST STE 1106
OAKLAND CA
94609-3125
US

V. Phone/Fax

Practice location:
  • Phone: 510-763-2662
  • Fax: 510-601-0750
Mailing address:
  • Phone: 510-763-2662
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberA97586
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA97586
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: