MEDICARE: DAVID WALLIS MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	A77627	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00A776270	OTHER	CA	BLUE SHIELD

General Provider Information

NPI Number	:	1255383139
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVID WALLIS MD

Provider Business Mailing Address
First Line	:	PO BOX 66657
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98166-0657
Country	:	US
Telephone Number	:	424-437-4700
Fax Number	:	424-437-8884

Provider Business Practice Location Address
First Line	:	520 N PROSPECT AVE STE 309
Second Line	:
City	:	REDONDO BEACH
State	:	CA
Zip	:	90277-3043
Country	:	US
Telephone Number	:	424-437-4700
Fax Number	:	424-437-8884

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/17/2006
Last Update Date	:	10/09/2024

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