Provider Demographics
NPI:1326022724
Name:WALLACE, SHARON RENEE (MD)
Entity Type:Individual
Prefix:MRS
First Name:SHARON
Middle Name:RENEE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1340 S DAMEN AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-1169
Mailing Address - Country:US
Mailing Address - Phone:773-292-4800
Mailing Address - Fax:312-564-4059
Practice Address - Street 1:2900 NORTH LOOP W STE 1300
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77092-8815
Practice Address - Country:US
Practice Address - Phone:773-292-4800
Practice Address - Fax:312-564-4059
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-30
Last Update Date:2018-03-17
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TXK0394207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX111778001Medicaid
TX111778001Medicaid
TX0513LMedicare PIN