Healthcare Provider Details

I. General information

NPI: 1497789077
Provider Name (Legal Business Name): DAVID MICHAEL WANALISTA D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 11/05/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10231 OLD OCEAN CITY BLVD SUITE 210
BERLIN MD
21811
US

IV. Provider business mailing address

9733 HEALTHWAY DRIVE
BERLIN MD
21811
US

V. Phone/Fax

Practice location:
  • Phone: 410-641-9482
  • Fax: 410-641-9516
Mailing address:
  • Phone: 856-691-8444
  • Fax: 856-691-8325

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number25MB07794500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: