Healthcare Provider Details

I. General information

NPI: 1952468233
Provider Name (Legal Business Name): PAUL ELLIOT WALLNER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 CARNIE BLVD SUITE 1
VOORHEES NJ
08043-4521
US

IV. Provider business mailing address

140 FELLSWOOD DR
MOORESTOWN NJ
08057-4015
US

V. Phone/Fax

Practice location:
  • Phone: 856-424-0003
  • Fax:
Mailing address:
  • Phone: 856-234-6336
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number25MB03618300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: