Provider Demographics
NPI:1891856738
Name:WALLACE, DONALD JOHN (DC)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:JOHN
Last Name:WALLACE
Suffix:
Gender:M
Credentials:DC
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Mailing Address - Street 1:127 SMITHTOWN BLVD STE 21
Mailing Address - Street 2:
Mailing Address - City:NESCONSET
Mailing Address - State:NY
Mailing Address - Zip Code:11767-1736
Mailing Address - Country:US
Mailing Address - Phone:631-360-0170
Mailing Address - Fax:631-361-6221
Practice Address - Street 1:127 SMITHTOWN BLVD STE 21
Practice Address - Street 2:
Practice Address - City:NESCONSET
Practice Address - State:NY
Practice Address - Zip Code:11767-1736
Practice Address - Country:US
Practice Address - Phone:631-360-0170
Practice Address - Fax:631-361-6221
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NYX008217-1111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA300026122Medicare PIN