Basic Information
| Provider Information | |||||||||
| NPI: | 1891779369 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALLACH | ||||||||
| FirstName: | STACEY | ||||||||
| MiddleName: | J. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4860 Y ST | ||||||||
| Address2: | OB/GYN, SUITE 2500, ACC | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958172307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167346930 | ||||||||
| FaxNumber: | 9167346666 | ||||||||
| Practice Location | |||||||||
| Address1: | 4860 Y ST | ||||||||
| Address2: | OB/GYN, SUITE 2500, ACC | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958172307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167346930 | ||||||||
| FaxNumber: | 9167346666 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2005 | ||||||||
| LastUpdateDate: | 12/06/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | G68624 | CA | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207VF0040X | A68624 | CA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Female Pelvic Medicine and Reconstructive Surgery |
ID Information
| ID | Type | State | Issuer | Description | 00A686240 | 05 | CA | MEDICAID |