Provider Demographics
NPI:1972665560
Name:WALLACE, MONICA L (MD)
Entity Type:Individual
Prefix:DR
First Name:MONICA
Middle Name:L
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:2101 E JEFFERSON ST PPQA MEDICARE COMPLIANCE UNIT 6 W
Mailing Address - Street 2:KAISER PERMANENTE MID ATL PERM MED GRP PC ATTN T BROOKS
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4908
Mailing Address - Country:US
Mailing Address - Phone:301-816-6660
Mailing Address - Fax:301-816-6308
Practice Address - Street 1:10810 CONNECTICUT AVENUE
Practice Address - Street 2:
Practice Address - City:KENSINGTON
Practice Address - State:MD
Practice Address - Zip Code:20895-2138
Practice Address - Country:US
Practice Address - Phone:301-929-7507
Practice Address - Fax:301-929-7114
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MDD0055090207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
H01048Medicare UPIN
003852M92Medicare ID - Type Unspecified