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General NPI Number Information
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NPI Number | 1154555738
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Entity Type | Individual
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Provider Name | ROBERT STEVEN WALLIS M.D.
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Gender | Male
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Dates
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Enumeration Date | 05/11/2009
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Last Update Date | 08/10/2021
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Provider Practice Location Address
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Address Line | 55 SAUNDERS HOLLOW RD
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City | OLD LYME
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State | CT
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Zip | 06371-1127
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Country | US
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Telephone | 860-598-9160
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Fax |
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Provider Business Mailing Address
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Address Line | 55 SAUNDERS HOLLOW RD
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City | OLD LYME
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State | CT
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Zip | 06371-1127
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Country | US
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Telephone | 860-598-9160
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RI0200X
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Taxonomy Name | Infectious Disease Physician
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License Number | MD037184
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License Number State | DC
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Taxonomy #2
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Taxonomy Code | 207RI0200X
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Taxonomy Name | Infectious Disease Physician
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License Number | 25MA07059900
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License Number State | NJ
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Taxonomy #3
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Taxonomy Code | 207RI0200X
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Taxonomy Name | Infectious Disease Physician
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License Number | 49370
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License Number State | CT
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