Provider Demographics
NPI:1114900362
Name:WALLACE, DERRICK I (MD)
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:I
Last Name:WALLACE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:187 WASHINTON AVE
Mailing Address - Street 2:SUITE 2I
Mailing Address - City:NUTLEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07110-1980
Mailing Address - Country:US
Mailing Address - Phone:973-235-0090
Mailing Address - Fax:973-842-0830
Practice Address - Street 1:187 WASHINGTON AVE
Practice Address - Street 2:SUITE 2I
Practice Address - City:NUTLEY
Practice Address - State:NJ
Practice Address - Zip Code:07110-3935
Practice Address - Country:US
Practice Address - Phone:973-235-0090
Practice Address - Fax:973-235-0090
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-22
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY208988207Y00000X
NJ25MA08175200207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02237176Medicaid
NY7M8681Medicare ID - Type Unspecified
NYH62271Medicare UPIN