Provider Demographics
NPI:1508832957
Name:WALLACE, LUISA PAULA (MD)
Entity Type:Individual
Prefix:DR
First Name:LUISA
Middle Name:PAULA
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 LOTHROP ST
Mailing Address - Street 2:ROOM 3950 CHP CMT
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15213-2546
Mailing Address - Country:US
Mailing Address - Phone:412-647-3553
Mailing Address - Fax:
Practice Address - Street 1:200 LOTHROP ST
Practice Address - Street 2:ROOM 3950 CHP CMT
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15213-2546
Practice Address - Country:US
Practice Address - Phone:412-647-3553
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD068609L2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001796800Medicaid
PAH14357Medicare UPIN
PA037336G89Medicare ID - Type Unspecified