Provider Demographics
NPI:1801942933
Name:WALLACE, THOMAS CLYDE (MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:CLYDE
Last Name:WALLACE
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Gender:M
Credentials:MD
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Mailing Address - Street 1:10 CONGRESS ST
Mailing Address - Street 2:SUITE 360
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-3023
Mailing Address - Country:US
Mailing Address - Phone:626-432-1640
Mailing Address - Fax:626-793-6381
Practice Address - Street 1:10 CONGRESS ST
Practice Address - Street 2:SUITE 360
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-3023
Practice Address - Country:US
Practice Address - Phone:626-432-1640
Practice Address - Fax:626-793-6381
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2023-03-07
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Provider Licenses
StateLicense IDTaxonomies
CAA-434902084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABW-0891552OtherDEA NUMBER
CAE-52039Medicare UPIN
CABW-0891552OtherDEA NUMBER