Provider Demographics
NPI:1982231205
Name:REGODON WALLIN, AMANDA MATILDA (MD, MPH)
Entity type:Individual
Prefix:
First Name:AMANDA MATILDA
Middle Name:
Last Name:REGODON WALLIN
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 ALAMEDA DE LAS PULGAS
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94403-1222
Mailing Address - Country:US
Mailing Address - Phone:650-573-3571
Mailing Address - Fax:650-572-9347
Practice Address - Street 1:1950 ALAMEDA DE LAS PULGAS
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94403-1222
Practice Address - Country:US
Practice Address - Phone:650-573-3571
Practice Address - Fax:650-572-9347
Is Sole Proprietor?:No
Enumeration Date:2020-03-25
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPTL40102084P0800X
390200000X
CAA1909352084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program