Agnes Soriano Wallbom, M.D., M.S.

Primary specialty

Physical Medicine & Rehabilitation PhysicianTaxonomy code 208100000X

License

G078095 Issued in CA

Practice address

11301 Wilshire Blvd # 117
Glavahs Dept PM&R
Los Angeles, CA 90073-1003

Phone

(310) 478-3711

Fax

(310) 268-4935

NPI assigned

Jul 1, 2006

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine, Master of Science

State licenses

Networks

• BSC 65 PLUS INDIVIDUAL MAPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1151712000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1183852800000",
    "number": "1316976509",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "11301 WILSHIRE BLVD # 117",
            "address_2": "GLAVAHS DEPT PM&R",
            "city": "LOS ANGELES",
            "state": "CA",
            "postal_code": "900731003",
            "telephone_number": "310-478-3711",
            "fax_number": "310-268-4935"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "11301 WILSHIRE BLVD # 117",
            "address_2": "GLAVAHS DEPT PM&R",
            "city": "LOS ANGELES",
            "state": "CA",
            "postal_code": "900731003",
            "telephone_number": "310-478-3711",
            "fax_number": "310-268-4935"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLBOM",
        "first_name": "AGNES",
        "middle_name": "SORIANO",
        "credential": "M.D., M.S.",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2006-07-01",
        "last_updated": "2007-07-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "208100000X",
            "taxonomy_group": "",
            "desc": "Physical Medicine & Rehabilitation",
            "state": "CA",
            "license": "G078095",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Shunte Wallace
• Torrionda Wallace, B.S.
• William Dean Wallace, MD
• Zemeris E Wallace
• Suzanne Marie Wallach, LMFT
• Drew Alan Walleck, ESQ.
• Donald E. Wallens, M.D.
• Jonathan M Waller, MA CCC-SLP
• Todd Steven Waller, M.D.
• Wynton Wallers

• Physical Medicine & Rehabilitation Physician in Los Angeles, CA
• Providers in Los Angeles, CA by specialty
• Physical Medicine & Rehabilitation Physician in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.