Provider Demographics
NPI:1487679627
Name:WALLACE, MATTHEW BREVARD III (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:BREVARD
Last Name:WALLACE
Suffix:III
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:PO BOX 9007
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22906-9007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1200 SUNSET LN STE 2210
Practice Address - Street 2:
Practice Address - City:CULPEPER
Practice Address - State:VA
Practice Address - Zip Code:22701-3376
Practice Address - Country:US
Practice Address - Phone:540-825-6100
Practice Address - Fax:540-825-1829
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2013-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101025059207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005624339Medicaid
VA005624339Medicaid
VA080005765Medicare PIN