Provider Demographics
NPI:1255867784
Name:WALLACE, MATTHEW MALONE (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:MALONE
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 1:9816 MAYLAND DR STE 100
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23233-1457
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9816 MAYLAND DR STE 100
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23233-1457
Practice Address - Country:US
Practice Address - Phone:804-282-8510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-03
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101274476207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery