=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275526253
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. JOHN DOUGLASS WALLOP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/25/2005
-----------------------------------------------------
Last Update Date | 05/09/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2661 RIVA RD BLDG 600, SUITE 601
-----------------------------------------------------
City | ANNAPOLIS
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21401-7353
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-266-6626
-----------------------------------------------------
Fax | 410-266-3026
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2661 RIVA RD BLDG 600, SUITE 601
-----------------------------------------------------
City | ANNAPOLIS
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21401-7353
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-266-6626
-----------------------------------------------------
Fax | 410-266-3026
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 17006
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2251P0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Physical Therapist
-----------------------------------------------------
License Number | 17006
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2251S0007X
-----------------------------------------------------
Taxonomy Name | Sports Physical Therapist
-----------------------------------------------------
License Number | 17006
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 2251X0800X
-----------------------------------------------------
Taxonomy Name | Orthopedic Physical Therapist
-----------------------------------------------------
License Number | 17006
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------