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General NPI Number Information
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NPI Number | 1497789077
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Entity Type | Individual
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Provider Name | DAVID MICHAEL WANALISTA D.O.
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Gender | Male
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Dates
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Enumeration Date | 07/10/2006
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Last Update Date | 11/05/2024
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Provider Practice Location Address
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Address Line | 10231 OLD OCEAN CITY BLVD SUITE 210
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City | BERLIN
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State | MD
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Zip | 21811
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Country | US
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Telephone | 410-641-9482
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Fax | 410-641-9516
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Provider Business Mailing Address
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Address Line | 9733 HEALTHWAY DRIVE
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City | BERLIN
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State | MD
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Zip | 21811
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Country | US
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Telephone | 856-691-8444
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Fax | 856-691-8325
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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 | 207RR0500X
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Taxonomy Name | Rheumatology Physician
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License Number | 25MB07794500
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License Number State | NJ
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