Provider Demographics
NPI:1023001138
Name:WALLACE, JANET NEASE (MD)
Entity Type:Individual
Prefix:
First Name:JANET
Middle Name:NEASE
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 4190
Mailing Address - Street 2:
Mailing Address - City:BARBOURSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25504-4190
Mailing Address - Country:US
Mailing Address - Phone:304-399-4405
Mailing Address - Fax:304-399-2526
Practice Address - Street 1:2900 1ST AVE
Practice Address - Street 2:OPC SUITE 30
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25702
Practice Address - Country:US
Practice Address - Phone:304-399-7280
Practice Address - Fax:304-399-7282
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV17387207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0309964Medicaid
KY7100350580Medicaid
WV0046053000Medicaid
WV0781201Medicare PIN
WV0046053000Medicaid
WVWV5368AMedicare PIN