Provider Demographics
NPI:1558323725
Name:WALLACE, HEATH WADE (IDC)
Entity Type:Individual
Prefix:MR
First Name:HEATH
Middle Name:WADE
Last Name:WALLACE
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1973 BIG BOULDER DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23456-6126
Mailing Address - Country:US
Mailing Address - Phone:757-471-1746
Mailing Address - Fax:
Practice Address - Street 1:USS THEODORE ROOSEVELT CVN 71
Practice Address - Street 2:MEDICAL DEPARTMENT
Practice Address - City:FPO
Practice Address - State:AE
Practice Address - Zip Code:09599 2871
Practice Address - Country:US
Practice Address - Phone:757-445-6230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman