Provider Demographics
NPI:1346340031
Name:WALLACE, WAYNE ARNOLD (MD)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:ARNOLD
Last Name:WALLACE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:9521 CRYSTAL BEACH RD
Mailing Address - Street 2:
Mailing Address - City:HAMMONDSPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14840-9340
Mailing Address - Country:US
Mailing Address - Phone:607-292-3505
Mailing Address - Fax:607-292-3505
Practice Address - Street 1:9521 CRYSTAL BEACH RD
Practice Address - Street 2:
Practice Address - City:HAMMONDSPORT
Practice Address - State:NY
Practice Address - Zip Code:14840-9340
Practice Address - Country:US
Practice Address - Phone:607-292-3505
Practice Address - Fax:607-292-3505
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY108875207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease