Provider Demographics
NPI:1285696203
Name:WALLERSTEIN, ROBERT JOSEPH (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:JOSEPH
Last Name:WALLERSTEIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16557 MARCHMONT DR
Mailing Address - Street 2:
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95032-5606
Mailing Address - Country:US
Mailing Address - Phone:408-335-8449
Mailing Address - Fax:
Practice Address - Street 1:655 E HUNTINGTON DR
Practice Address - Street 2:
Practice Address - City:MONROVIA
Practice Address - State:CA
Practice Address - Zip Code:91016
Practice Address - Country:US
Practice Address - Phone:626-471-7455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2019-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG88350207SG0201X, 208000000X
NJMA58385207SC0300X, 207SG0201X, 208000000X
HIMD-18671208000000X, 207SG0201X, 207SC0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)
No207SC0300XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Cytogenetics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01704714Medicaid
NY01704714Medicaid
NY01704714Medicaid