Provider Demographics
NPI:1730247149
Name:WALLACH, ROBERT S (DO)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:S
Last Name:WALLACH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 RIVERGATE LN STE B1-101
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-7470
Mailing Address - Country:US
Mailing Address - Phone:970-970-4269
Mailing Address - Fax:833-975-0954
Practice Address - Street 1:555 RIVERGATE LN STE B1-101
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-7470
Practice Address - Country:US
Practice Address - Phone:970-403-3324
Practice Address - Fax:833-975-0954
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO46615208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCO300853Medicare PIN