Provider Demographics
NPI:1669479713
Name:WALLACE, MELISSA A (DO)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:A
Last Name:WALLACE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:752 WAYCROSS RD
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45240-3184
Mailing Address - Country:US
Mailing Address - Phone:513-825-9595
Mailing Address - Fax:513-589-3747
Practice Address - Street 1:752 WAYCROSS RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45240-3184
Practice Address - Country:US
Practice Address - Phone:513-825-9595
Practice Address - Fax:513-589-3747
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34007996W208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics