Provider Demographics
NPI:1578502191
Name:WALLACE, ERIC (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
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 1:4100 GUARDIAN ST
Mailing Address - Street 2:STE 205
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93063-6721
Mailing Address - Country:US
Mailing Address - Phone:855-504-4544
Mailing Address - Fax:855-577-2018
Practice Address - Street 1:168 N BRENT ST
Practice Address - Street 2:SUITE 402
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-2817
Practice Address - Country:US
Practice Address - Phone:888-234-0004
Practice Address - Fax:805-641-3965
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2017-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA851952085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A851950OtherBLUESHIELD OF CA
CA00A851950Medicaid
I30144Medicare UPIN
CA00A851950OtherBLUESHIELD OF CA
CA00A851950Medicaid