MEDICARE: DR. JOHN WALLMAN DC

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	111NN1001X	Nutrition Chiropractor	2887	NY
2	111NN1001X	Nutrition Chiropractor	1329	MA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	Y35962	OTHER	MA	BC/BS
2	2887	OTHER	NY	CHIROPRACTIC LICENSE
3	1329	OTHER	MA	MASSACHUSETTS LICENSE
4	625080	OTHER	MA	CIGNA PIN
5	798258	OTHER	MA	TUFTS PROVIDER #
6	227986	OTHER	NY	NEW YORK WORKERS COMPENSATION

General Provider Information

NPI Number	:	1942567235
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN WALLMAN DC

Provider Business Mailing Address
First Line	:	2805 VETERANS MEMORIAL HWY
Second Line	:	STE 8
City	:	RONKONKOMA
State	:	NY
Zip	:	11779-7680
Country	:	US
Telephone Number	:	631-440-7008
Fax Number	:

Provider Business Practice Location Address
First Line	:	2805 VETERANS MEMORIAL HWY
Second Line	:	STE 8
City	:	RONKONKOMA
State	:	NY
Zip	:	11779-7680
Country	:	US
Telephone Number	:	631-440-7008
Fax Number	:

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

Provider Enumeration Date	:	04/12/2012
Last Update Date	:	04/08/2016

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Directions to “ DR. JOHN WALLMAN DC” Practice Location

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