Provider Demographics
NPI:1164447215
Name:WALLACE, CHRISTOPHER ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:ALAN
Last Name:WALLACE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 840294
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-0294
Mailing Address - Country:US
Mailing Address - Phone:888-344-1160
Mailing Address - Fax:972-331-3148
Practice Address - Street 1:270 FARMINGTON AVENUE
Practice Address - Street 2:SUITE 332
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06089
Practice Address - Country:US
Practice Address - Phone:888-276-2223
Practice Address - Fax:972-767-0225
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2013-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT041939207ZD0900X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAH89511Medicare UPIN
22BDDTBMedicare ID - Type Unspecified