Active NPI
Peter Michael Wallach, M.D.
- Dermatology Physician
- Coral Springs, FL
National Provider Identifier
1710987391
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dermatology Physician
- License
- ME0029164
- Practice address
- 1480 N University Dr
Coral Springs, FL 33071-6040 - Phone
- (954) 753-1030
- Fax
- (954) 753-1115
- NPI assigned
- Jul 26, 2005
- Reactivated
- Mar 30, 2006
- Last updated
- Jul 15, 2010
- 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 |
|---|---|---|---|---|
| Dermatology Physician | 207N00000X | ME0029164 | FL | Primary |
Addresses
Primary practice location
1480 N University Dr
Coral Springs, FL 33071-6040
Mailing address
1480 N University Dr
Coral Springs, FL 33071-6040
Phone (954) 753-1030
Other identifiers 5
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 0008978 | Other | FL | GHI PROVIDER ID |
| 406073297 | Other | FL | RR MEDICARE |
| 0706177 | Other | FL | AETNA ID |
| 057349300 | Medicaid | FL | |
| 4958275 | Other | FL | CIGNA ID |
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)
- Enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| ME0029164 | FL | MD | Dermatology Physician |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1122336000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1279152000000",
"number": "1710987391",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1480 N UNIVERSITY DR",
"city": "CORAL SPRINGS",
"state": "FL",
"postal_code": "330716040",
"telephone_number": "954-753-1030",
"fax_number": "954-753-1115"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1480 N UNIVERSITY DR",
"city": "CORAL SPRINGS",
"state": "FL",
"postal_code": "330716040",
"telephone_number": "954-753-1030",
"fax_number": "954-753-1115"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WALLACH",
"first_name": "PETER",
"middle_name": "MICHAEL",
"name_prefix": "Dr.",
"credential": "M.D.",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2005-07-26",
"last_updated": "2010-07-15",
"deactivation_date": "2006-03-21",
"reactivation_date": "2006-03-30",
"status": "A"
},
"taxonomies": [
{
"code": "207N00000X",
"taxonomy_group": "",
"desc": "Dermatology",
"state": "FL",
"license": "ME0029164",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "GHI PROVIDER ID",
"identifier": "0008978",
"state": "FL"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "RR MEDICARE",
"identifier": "406073297",
"state": "FL"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "AETNA ID",
"identifier": "0706177",
"state": "FL"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "057349300",
"state": "FL"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "CIGNA ID",
"identifier": "4958275",
"state": "FL"
}
],
"endpoints": [],
"other_names": []
}Other providers in Coral Springs, FL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 15, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.