Provider Demographics
NPI:1205861606
Name:WALLACE, VIRGINIA L (MD)
Entity type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:L
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 1:8901 W LINCOLN AVENUE
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53227-2477
Mailing Address - Country:US
Mailing Address - Phone:414-328-7950
Mailing Address - Fax:414-328-8505
Practice Address - Street 1:8901 W LINCOLN AVENUE
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-2477
Practice Address - Country:US
Practice Address - Phone:414-328-7950
Practice Address - Fax:414-328-8505
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI41111207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
G98808Medicare UPIN