Healthcare Provider Details

I. General information

NPI: 1689674905
Provider Name (Legal Business Name): WILLIAM TODD WALLENS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3754 MILITARY RD
NIAGARA FALLS NY
14305-3517
US

IV. Provider business mailing address

3754 MILITARY RD
NIAGARA FALLS NY
14305-3517
US

V. Phone/Fax

Practice location:
  • Phone: 716-298-4330
  • Fax:
Mailing address:
  • Phone: 716-298-4330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number116615
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: