Provider Demographics
NPI:1467438937
Name:WALLACE, MICHAEL LLOYD (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LLOYD
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 1:522 ALPHA DR
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15238-2912
Mailing Address - Country:US
Mailing Address - Phone:412-968-9266
Mailing Address - Fax:412-968-5673
Practice Address - Street 1:522 ALPHA DR
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15238-2912
Practice Address - Country:US
Practice Address - Phone:412-968-9266
Practice Address - Fax:412-968-5673
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD073644L207ZD0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA050657Medicare ID - Type Unspecified
G54976Medicare UPIN