Healthcare Provider Details

I. General information

NPI: 1578026316
Provider Name (Legal Business Name): REBECCA WALLACH DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2019
Last Update Date: 08/01/2023
Certification Date: 08/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2345 MAIN ST
TEWKSBURY MA
01876-3125
US

IV. Provider business mailing address

2345 MAIN ST
TEWKSBURY MA
01876-3125
US

V. Phone/Fax

Practice location:
  • Phone: 978-658-9931
  • Fax: 978-694-0991
Mailing address:
  • Phone: 978-658-9931
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number292633
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: