Provider Demographics
NPI:1104395656
Name:AL-HERTANI, WALLA (MD)
Entity type:Individual
Prefix:DR
First Name:WALLA
Middle Name:
Last Name:AL-HERTANI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 W LA VETA AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-4203
Mailing Address - Country:US
Mailing Address - Phone:714-509-4873
Mailing Address - Fax:714-509-4788
Practice Address - Street 1:1201 W LA VETA AVE
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4203
Practice Address - Country:US
Practice Address - Phone:714-509-4873
Practice Address - Fax:714-509-4788
Is Sole Proprietor?:No
Enumeration Date:2018-11-14
Last Update Date:2024-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC196993207SG0201X
ZZ024227207SG0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207SG0202XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Biochemical Genetics
Yes207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)