Provider Demographics
NPI:1003255605
Name:WALLACE, SARA SHEEHAN (MD)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:SHEEHAN
Last Name:WALLACE
Suffix:
Gender:F
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:PO BOX 6069
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29171-6069
Mailing Address - Country:US
Mailing Address - Phone:803-359-8855
Mailing Address - Fax:803-794-6480
Practice Address - Street 1:3240 SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-3428
Practice Address - Country:US
Practice Address - Phone:803-359-8855
Practice Address - Fax:803-794-6480
Is Sole Proprietor?:No
Enumeration Date:2013-06-18
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL35809208000000X
SC35809208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC358099Medicaid
SC35809OtherSC MEDICAL LICENSE
SC358099Medicaid
SCSC8403F935Medicare PIN