Provider Demographics
NPI:1336116656
Name:WALLACE, DAVID M (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:M
Last Name:WALLACE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 8000
Mailing Address - Street 2:DEPT 596
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14267-0002
Mailing Address - Country:US
Mailing Address - Phone:866-295-0041
Mailing Address - Fax:708-342-2517
Practice Address - Street 1:73 S BATH AVE
Practice Address - Street 2:
Practice Address - City:LONG BRANCH
Practice Address - State:NJ
Practice Address - Zip Code:07740-5725
Practice Address - Country:US
Practice Address - Phone:732-870-3600
Practice Address - Fax:732-870-0119
Is Sole Proprietor?:No
Enumeration Date:2006-03-06
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MA04221200207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2462907Medicaid
NJC28837Medicare UPIN
NJ2462907Medicaid