Provider Demographics
NPI:1831622828
Name:WALLACE, SHARI (MD)
Entity type:Individual
Prefix:DR
First Name:SHARI
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2570 ROUTE 9W STE 10
Mailing Address - Street 2:
Mailing Address - City:CORNWALL
Mailing Address - State:NY
Mailing Address - Zip Code:12518-1370
Mailing Address - Country:US
Mailing Address - Phone:845-220-3100
Mailing Address - Fax:845-534-2940
Practice Address - Street 1:14 GROVE ST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10940-4806
Practice Address - Country:US
Practice Address - Phone:845-563-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-06
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-0026596208000000X
NY310882208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics