Healthcare Provider Details

I. General information

NPI: 1710927132
Provider Name (Legal Business Name): WAYNE WALLENDER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 12/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 E PRIMROSE ST
SPRINGFIELD MO
65807-5155
US

IV. Provider business mailing address

PO BOX 9007
SPRINGFIELD MO
65808-9007
US

V. Phone/Fax

Practice location:
  • Phone: 417-875-3095
  • Fax: 417-875-3570
Mailing address:
  • Phone: 417-875-3462
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License NumberR1P10
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberR1P10
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: