Provider Demographics
NPI:1235140930
Name:WALLACE, SANDRA LOUISE (MD)
Entity Type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:LOUISE
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 1449
Mailing Address - Street 2:
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92822-1449
Mailing Address - Country:US
Mailing Address - Phone:714-996-1633
Mailing Address - Fax:714-996-9267
Practice Address - Street 1:50 ALESSANDRO PL
Practice Address - Street 2:SUITE 360
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-3149
Practice Address - Country:US
Practice Address - Phone:626-793-6133
Practice Address - Fax:626-793-6135
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2011-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG403910207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G403910Medicaid
110010430OtherRAILROAD RETIREMENT
CA00G403910OtherBLUE SHIELD
A92183Medicare UPIN
110010430OtherRAILROAD RETIREMENT