Provider Demographics
NPI:1679576276
Name:WALLACE, DAVID ALAN (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:ALAN
Last Name:WALLACE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:11600 WILSHIRE BLVD
Mailing Address - Street 2:STE 200
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-1782
Mailing Address - Country:US
Mailing Address - Phone:310-828-2020
Mailing Address - Fax:310-914-3009
Practice Address - Street 1:11600 WILSHIRE BLVD
Practice Address - Street 2:STE 200
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-1782
Practice Address - Country:US
Practice Address - Phone:310-828-2020
Practice Address - Fax:310-914-3009
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2010-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG37076207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG37076OtherCA MEDICAL LICENSE
CAG37076BMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
CAG37076OtherCA MEDICAL LICENSE