Active NPI
Michael S. Wallack, M.D.
- Internal Medicine Physician
- San Fernando, CA
National Provider Identifier
1689791139
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Internal Medicine Physician
- License
- G12118
- Practice address
- 1600 San Fernando Road
San Fernando, CA 91340 - Phone
- (818) 365-8086
- Fax
- (818) 898-4826
- NPI assigned
- Mar 22, 2007
- Last updated
- Jul 8, 2007
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Internal Medicine Physician | 207R00000X | G12118 | CA | Primary |
Addresses
Primary practice location
1600 San Fernando Road
San Fernando, CA 91340
Mailing address
4801 Brandenburg
Tarzana, CA 91350
Phone (818) 342-4440
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| G12118 | CA | MD | Internal Medicine Physician |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1174521600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1689791139",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "4801 BRANDENBURG",
"city": "TARZANA",
"state": "CA",
"postal_code": "91350",
"telephone_number": "818-342-4440",
"fax_number": "818-342-9710"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1600 SAN FERNANDO ROAD",
"city": "SAN FERNANDO",
"state": "CA",
"postal_code": "91340",
"telephone_number": "818-365-8086",
"fax_number": "818-898-4826"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WALLACK",
"first_name": "MICHAEL",
"middle_name": "S.",
"credential": "M.D.",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2007-03-22",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "207R00000X",
"taxonomy_group": "",
"desc": "Internal Medicine",
"state": "CA",
"license": "G12118",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in San Fernando, CA
Sources for this page
- 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.