Provider Demographics
NPI:1629023239
Name:WALLACE, SHARON K (MD)
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:K
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 1:70 DOCTORS' PARK
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703
Mailing Address - Country:US
Mailing Address - Phone:573-334-6071
Mailing Address - Fax:573-334-4739
Practice Address - Street 1:70 DOCTORS' PARK
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703
Practice Address - Country:US
Practice Address - Phone:573-334-6071
Practice Address - Fax:573-334-4739
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2013-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00632052085R0202X
MO20090089722085R0202X, 2085N0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDKDA7 / 645989-01OtherBC / BS OF MD
MDS187 / 0024OtherBLUECHOICE
MD408165000Medicaid
MDS187 / 0024OtherBLUECHOICE
S794 / L742Medicare ID - Type Unspecified