Provider Demographics
NPI:1255642930
Name:WALLACE, JANIKA INEZ (DO)
Entity type:Individual
Prefix:
First Name:JANIKA
Middle Name:INEZ
Last Name:WALLACE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:104 E CECIL AVE
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:NORTH EAST
Mailing Address - State:MD
Mailing Address - Zip Code:21901-4016
Mailing Address - Country:US
Mailing Address - Phone:410-287-7021
Mailing Address - Fax:410-287-7067
Practice Address - Street 1:104 E CECIL AVE
Practice Address - Street 2:1ST FLOOR
Practice Address - City:NORTH EAST
Practice Address - State:MD
Practice Address - Zip Code:21901-4016
Practice Address - Country:US
Practice Address - Phone:410-287-7021
Practice Address - Fax:410-287-7067
Is Sole Proprietor?:No
Enumeration Date:2010-06-28
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ25MB09205500207Q00000X
MDH0075972207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD301409Y2BOtherMEDICARE