Provider Demographics
NPI:1457346967
Name:WALLACE, JOHN R (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:WALLACE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:4602 DEPT
Mailing Address - Street 2:
Mailing Address - City:CAROL STREAM
Mailing Address - State:IL
Mailing Address - Zip Code:60122-0021
Mailing Address - Country:US
Mailing Address - Phone:906-225-7601
Mailing Address - Fax:906-225-7453
Practice Address - Street 1:1414 W FAIR AVE
Practice Address - Street 2:SUITE 111
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-2675
Practice Address - Country:US
Practice Address - Phone:906-225-7601
Practice Address - Fax:906-225-7453
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2009-04-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301075195207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIJW075195OtherBCBSM
MI110189987OtherRAILROAD MEDICARE
MI4138271Medicaid
MI4138271Medicaid
MI0N113700003Medicare PIN