Provider Demographics
NPI:1154555738
Name:WALLIS, ROBERT STEVEN (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:STEVEN
Last Name:WALLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:55 SAUNDERS HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:OLD LYME
Mailing Address - State:CT
Mailing Address - Zip Code:06371-1127
Mailing Address - Country:US
Mailing Address - Phone:860-598-9160
Mailing Address - Fax:
Practice Address - Street 1:55 SAUNDERS HOLLOW RD
Practice Address - Street 2:
Practice Address - City:OLD LYME
Practice Address - State:CT
Practice Address - Zip Code:06371-1127
Practice Address - Country:US
Practice Address - Phone:860-598-9160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-11
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD037184207RI0200X
NJ25MA07059900207RI0200X
CT49370207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease