Provider Demographics
NPI:1477520195
Name:GARRIS WALLACE, SHEILA MAE (MD)
Entity Type:Individual
Prefix:MRS
First Name:SHEILA
Middle Name:MAE
Last Name:GARRIS WALLACE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MISS
Other - First Name:SHEILA
Other - Middle Name:MAE
Other - Last Name:GARRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1800 GLENSIDE DR
Mailing Address - Street 2:STE 105
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-3769
Mailing Address - Country:US
Mailing Address - Phone:804-288-0399
Mailing Address - Fax:804-285-0088
Practice Address - Street 1:1800 GLENSIDE DR STE 101
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-3769
Practice Address - Country:US
Practice Address - Phone:804-288-3001
Practice Address - Fax:804-673-5614
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101040429207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005832918Medicaid
VA110193042OtherRAILROAD MEDICARE
VA141505OtherANTHEM
VA1477520195Medicaid
VA141505OtherANTHEM
VA110193042OtherRAILROAD MEDICARE
P00723189Medicare PIN