=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285672154
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOSEPH J WALLIS DO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2006
-----------------------------------------------------
Last Update Date | 01/23/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 600 MOUNT PLEASANT AVE SUITE G
-----------------------------------------------------
City | DOVER
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07801-1629
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-989-9000
-----------------------------------------------------
Fax | 973-989-8225
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 600 MOUNT PLEASANT AVE SUITE G
-----------------------------------------------------
City | DOVER
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07801-1629
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-989-9000
-----------------------------------------------------
Fax | 973-989-8225
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | 25MB02488400
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------