Healthcare Provider Details

I. General information

NPI: 1114929403
Provider Name (Legal Business Name): WALLACE C GAUNTNER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 01/15/2020
Certification Date: 01/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

824 CALIFORNIA AVE
PITTSBURGH PA
15202-2706
US

IV. Provider business mailing address

824 CALIFORNIA AVE
PITTSBURGH PA
15202-2706
US

V. Phone/Fax

Practice location:
  • Phone: 412-766-3232
  • Fax: 412-766-4320
Mailing address:
  • Phone: 412-766-3232
  • Fax: 412-766-4320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number35068280
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberMD019281E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: