Provider Demographics
NPI:1841229234
Name:WALLACE, CHRISTINE (MD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTINE
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4685 FOREST AVE STE C
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45212-3359
Mailing Address - Country:US
Mailing Address - Phone:513-246-7796
Mailing Address - Fax:513-852-8525
Practice Address - Street 1:8040 PRINCETON-GLENDALE RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45069-0000
Practice Address - Country:US
Practice Address - Phone:513-246-7000
Practice Address - Fax:513-246-5479
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35066571207R00000X, 2083B0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083B0002XAllopathic & Osteopathic PhysiciansPreventive MedicineObesity Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0324107Medicaid
OHG23679Medicare UPIN
OH0324107Medicaid