Healthcare Provider Details

I. General information

NPI: 1417923863
Provider Name (Legal Business Name): COREY J WALLACH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2006
Last Update Date: 02/01/2025
Certification Date: 02/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 S SHIRLINGTON RD STE 1100
ARLINGTON VA
22206-3605
US

IV. Provider business mailing address

2800 S SHIRLINGTON RD STE 1100
ARLINGTON VA
22206-3605
US

V. Phone/Fax

Practice location:
  • Phone: 703-892-6500
  • Fax: 703-892-1550
Mailing address:
  • Phone: 703-892-6500
  • Fax: 703-892-1550

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMD425770
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberA95705
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License NumberA95705
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: