Provider Demographics
NPI:1679567192
Name:WALLACE, LAWRENCE (MD)
Entity Type:Individual
Prefix:MR
First Name:LAWRENCE
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 1:1225 WARM SPRINGS AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGDON
Mailing Address - State:PA
Mailing Address - Zip Code:16652-2350
Mailing Address - Country:US
Mailing Address - Phone:814-643-8556
Mailing Address - Fax:814-643-7014
Practice Address - Street 1:790 BRYAN ST
Practice Address - Street 2:SUITE 1
Practice Address - City:HUNTINGDON
Practice Address - State:PA
Practice Address - Zip Code:16652-2410
Practice Address - Country:US
Practice Address - Phone:814-643-8484
Practice Address - Fax:814-643-8487
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2012-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101234728207X00000X
PAMD439714207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010114446Medicaid
VAH91767Medicare UPIN
VA00W205O01Medicare ID - Type Unspecified