Provider Demographics
NPI:1841201860
Name:WALLACE, MARCUS (MD)
Entity Type:Individual
Prefix:
First Name:MARCUS
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:PO BOX 2666
Mailing Address - Street 2:HOSPITAL MEDICINE
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70404-2666
Mailing Address - Country:US
Mailing Address - Phone:985-230-3066
Mailing Address - Fax:985-230-2072
Practice Address - Street 1:15790 PAUL VEGA MD DR
Practice Address - Street 2:HOSPITAL MEDICINE
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403-1434
Practice Address - Country:US
Practice Address - Phone:985-230-3066
Practice Address - Fax:985-230-2072
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ35540207R00000X
LAMD.025294208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ143374-01Medicaid
LA302440YH97Medicare PIN
AZ143374-01Medicaid
AZZ110607Medicare PIN
AZP00336267Medicare PIN