Provider Demographics
NPI:1851665541
Name:WALLACE, ELIZABETH ANNE (MD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:ANNE
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 1:309 RUNNING CEDAR LN
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23229-7953
Mailing Address - Country:US
Mailing Address - Phone:804-282-1918
Mailing Address - Fax:
Practice Address - Street 1:2384 COLONY CROSSING PL
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-4280
Practice Address - Country:US
Practice Address - Phone:804-423-3636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-28
Last Update Date:2012-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101251402207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism