Healthcare Provider Details

I. General information

NPI: 1285634071
Provider Name (Legal Business Name): ELIZABETH WALLEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2005
Last Update Date: 05/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 CALLE CAL
SANTA FE NM
87508
US

IV. Provider business mailing address

20 CALLE CAL
SANTA FE NM
87508-9158
US

V. Phone/Fax

Practice location:
  • Phone: 614-266-8533
  • Fax:
Mailing address:
  • Phone: 614-266-8533
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number35055437
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35-055437
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberMD000025868
License Number StateNM
# 4
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberMD43857E
License Number StatePA
# 5
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number35.055437
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: