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General NPI Number Information
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NPI Number | 1881989085
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Entity Type | Organization
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Legal Business Name | JAMES I. WALLSTROM, M.D., INC.
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Dates
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Enumeration Date | 06/15/2011
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Last Update Date | 05/16/2012
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Provider Practice Location Address
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Address Line | 50 BELLEFONTAINE ST STE 205
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City | PASADENA
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State | CA
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Zip | 91105-3132
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Country | US
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Telephone | 626-792-4115
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Fax | 626-792-3103
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Provider Business Mailing Address
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Address Line | 50 BELLEFONTAINE ST STE 205
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City | PASADENA
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State | CA
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Zip | 91105-3132
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Country | US
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Telephone | 626-792-4115
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Fax | 626-792-3103
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Authorized Official
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Title or Position | PRESIDENT
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Name | JAMES I WALLSTROM
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Credential | M.D.
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Telephone | 626-792-4115
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | G74317
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License Number State | CA
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