Provider Demographics
NPI:1609804350
Name:WALLACE, OLUKEMI A (MD)
Entity Type:Individual
Prefix:DR
First Name:OLUKEMI
Middle Name:A
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:15342 HAWTHORNE BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:LAWNDALE
Mailing Address - State:CA
Mailing Address - Zip Code:90260-2152
Mailing Address - Country:US
Mailing Address - Phone:310-644-8400
Mailing Address - Fax:310-644-8424
Practice Address - Street 1:15342 HAWTHORNE BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:LAWNDALE
Practice Address - State:CA
Practice Address - Zip Code:90260-2152
Practice Address - Country:US
Practice Address - Phone:310-644-8400
Practice Address - Fax:310-644-8424
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-30
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA48240174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist