Provider Demographics
NPI:1497789077
Name:WANALISTA, DAVID MICHAEL (DO)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:MICHAEL
Last Name:WANALISTA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:9733 HEALTHWAY DRIVE
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:MD
Mailing Address - Zip Code:21811
Mailing Address - Country:US
Mailing Address - Phone:856-691-8444
Mailing Address - Fax:856-691-8325
Practice Address - Street 1:10231 OLD OCEAN CITY BLVD
Practice Address - Street 2:SUITE 210
Practice Address - City:BERLIN
Practice Address - State:MD
Practice Address - Zip Code:21811
Practice Address - Country:US
Practice Address - Phone:410-641-9482
Practice Address - Fax:410-641-9516
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MB07794500207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD193571200Medicaid
NJ086324Medicare ID - Type Unspecified
NJ1965312Medicaid