Provider Demographics
NPI:1609142074
Name:WALLACE, GABRIEL ABRAHAM (MD)
Entity Type:Individual
Prefix:DR
First Name:GABRIEL
Middle Name:ABRAHAM
Last Name:WALLACE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 84992
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60689-4992
Mailing Address - Country:US
Mailing Address - Phone:918-710-3710
Mailing Address - Fax:918-770-0058
Practice Address - Street 1:12251 S 80TH AVE STE 1520
Practice Address - Street 2:
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1290
Practice Address - Country:US
Practice Address - Phone:708-923-4200
Practice Address - Fax:708-923-4201
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-29
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036142476208600000X, 2086S0129X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036142476Medicaid