Provider Demographics
NPI:1013957034
Name:WALLACE, RICHARD AUSTIN (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:AUSTIN
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 1:1306 KANAWHA BLVD E
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-3001
Mailing Address - Country:US
Mailing Address - Phone:304-343-4371
Mailing Address - Fax:304-353-0215
Practice Address - Street 1:1306 KANAWHA BLVD E
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-3001
Practice Address - Country:US
Practice Address - Phone:304-343-4371
Practice Address - Fax:304-353-0215
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV11648207YX0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0901XAllopathic & Osteopathic PhysiciansOtolaryngologyOtology & Neurotology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1013957034OtherNPI
WV010107500Medicaid
WV0493522Medicare PIN
WV010107500Medicaid
WVB42591Medicare UPIN