Provider Demographics
NPI:1780998112
Name:WALLACE, CORY L (DPM)
Entity type:Individual
Prefix:
First Name:CORY
Middle Name:L
Last Name:WALLACE
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:CORY
Other - Middle Name:
Other - Last Name:WELLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8715 VILLAGE DR
Mailing Address - Street 2:STE 400
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78217-5407
Mailing Address - Country:US
Mailing Address - Phone:210-732-3668
Mailing Address - Fax:210-732-3338
Practice Address - Street 1:8715 VILLAGE DR STE 400
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78217-5407
Practice Address - Country:US
Practice Address - Phone:210-732-3668
Practice Address - Fax:210-732-3338
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-27
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2047213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX297723YMVUOtherWMG PTAN