Provider Demographics
NPI:1740626654
Name:WALLACE, ANDREW BLAKE (MD)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:BLAKE
Last Name:WALLACE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1025 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-7354
Mailing Address - Country:US
Mailing Address - Phone:910-762-3882
Mailing Address - Fax:
Practice Address - Street 1:510 S KINGSHIGHWAY BLVD
Practice Address - Street 2:MALLINCKRODT INSTITUE OF RADIOLOGY
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1016
Practice Address - Country:US
Practice Address - Phone:314-362-2978
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-18
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC2020-045832085R0202X
MO20140139322085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology