Healthcare Provider Details

I. General information

NPI: 1275526253
Provider Name (Legal Business Name): MR. JOHN DOUGLASS WALLOP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MR. DOUG WALLOP

II. Dates (important events)

Enumeration Date: 08/25/2005
Last Update Date: 05/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2661 RIVA RD BLDG 600, SUITE 601
ANNAPOLIS MD
21401-7353
US

IV. Provider business mailing address

2661 RIVA RD BLDG 600, SUITE 601
ANNAPOLIS MD
21401-7353
US

V. Phone/Fax

Practice location:
  • Phone: 410-266-6626
  • Fax: 410-266-3026
Mailing address:
  • Phone: 410-266-6626
  • Fax: 410-266-3026

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number17006
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number17006
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number17006
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number17006
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: