Provider Demographics
NPI:1841213667
Name:WALLACE, WAYMON L (MD)
Entity Type:Individual
Prefix:
First Name:WAYMON
Middle Name:L
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 40535
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45240-0535
Mailing Address - Country:US
Mailing Address - Phone:513-403-3762
Mailing Address - Fax:513-521-6403
Practice Address - Street 1:1577 GOODMAN AVE STE A
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45224-1044
Practice Address - Country:US
Practice Address - Phone:513-403-3762
Practice Address - Fax:513-521-6403
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35076674207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2232177Medicaid
H12466Medicare UPIN
OHH124290Medicare PIN