Healthcare Provider Details

I. General information

NPI: 1265404198
Provider Name (Legal Business Name): CHARLES THOMAS WALLACK D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/04/2006
Last Update Date: 01/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 CHAPEL HILL RD
LINCOLN PARK NJ
07035-1719
US

IV. Provider business mailing address

10 CHAPEL HILL RD
LINCOLN PARK NJ
07035-1719
US

V. Phone/Fax

Practice location:
  • Phone: 973-694-5632
  • Fax:
Mailing address:
  • Phone: 973-694-5632
  • Fax: 973-694-1233

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number25MD00140200
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number25MD00140200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: