Individual
DR. ERIC D WALLISA
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
5955 S EMERSON AVE, 100, INDIANAPOLIS, IN 46237-2525
(317) 789-9600
(317) 789-0600
Mailing address
5955 S EMERSON AVE, 100, INDIANAPOLIS, IN 46237-2525
(317) 789-9600
(317) 789-0600
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
01054688A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
01054688A
STATE MEDICAL LICENSE
IN
01
—
01054688B
STATE CSR
IN
Enumeration date
03/10/2006
Last updated
03/07/2023
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