Provider Demographics
NPI:1720013121
Name:WALLACE, TIMOTHY M (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:M
Last Name:WALLACE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:8901 W LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53227-2409
Mailing Address - Country:US
Mailing Address - Phone:414-328-7950
Mailing Address - Fax:414-328-8505
Practice Address - Street 1:36500 AURORA DR
Practice Address - Street 2:
Practice Address - City:SUMMIT
Practice Address - State:WI
Practice Address - Zip Code:53066-4899
Practice Address - Country:US
Practice Address - Phone:262-434-3741
Practice Address - Fax:262-434-3702
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI41030207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
H08522Medicare UPIN