Provider Demographics
NPI:1437685914
Name:WALLACE, SIMON ANDREW (MD)
Entity type:Individual
Prefix:DR
First Name:SIMON
Middle Name:ANDREW
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 1:301 LIPPINCOTT DR STE 410
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-4197
Mailing Address - Country:US
Mailing Address - Phone:856-355-7155
Mailing Address - Fax:856-325-4798
Practice Address - Street 1:536 LIPPINCOTT DR
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-4805
Practice Address - Country:US
Practice Address - Phone:856-355-7155
Practice Address - Fax:856-325-4798
Is Sole Proprietor?:No
Enumeration Date:2017-05-03
Last Update Date:2025-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA12907600207RH0002X, 208100000X
WI7636-851208100000X
PAMD477813207RH0002X
WI72026208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation