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General NPI Number Information
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NPI Number | 1902144694
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Entity Type | Individual
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Provider Name | WALLACE JACK SCHWAM M.D.
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Gender | Male
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Dates
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Enumeration Date | 01/30/2013
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Last Update Date | 01/30/2013
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Provider Practice Location Address
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Address Line | 210 INDIO DR
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City | PISMO BEACH
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State | CA
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Zip | 93449-1514
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Country | US
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Telephone | 805-231-8699
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1158
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City | SOLVANG
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State | CA
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Zip | 93464-1158
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Country | US
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Telephone | 805-231-8699
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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 | 207RG0300X
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Taxonomy Name | Geriatric Medicine (Internal Medicine) Physician
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License Number | GFE12267
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License Number State | CA
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