Provider Demographics
NPI:1255713301
Name:WALLACE, NOAH ISADORE (DO)
Entity type:Individual
Prefix:DR
First Name:NOAH
Middle Name:ISADORE
Last Name:WALLACE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:633 MEDICAL GROUP
Mailing Address - Street 2:77 NEALY AVE
Mailing Address - City:LANGLEY AFB
Mailing Address - State:VA
Mailing Address - Zip Code:23665
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:502 W BROAD ST STE 2
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22046-3206
Practice Address - Country:US
Practice Address - Phone:571-421-8431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-25
Last Update Date:2025-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102205033207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine