Provider Demographics
NPI:1982353637
Name:WALLACE, ZACHARY C (MD)
Entity Type:Individual
Prefix:
First Name:ZACHARY
Middle Name:C
Last Name:WALLACE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8720 N DEERWOOD DR APT 115
Mailing Address - Street 2:
Mailing Address - City:BROWN DEER
Mailing Address - State:WI
Mailing Address - Zip Code:53209-1321
Mailing Address - Country:US
Mailing Address - Phone:262-389-6487
Mailing Address - Fax:
Practice Address - Street 1:2801 W KINNICKINNIC RIVER PKWY STE 250
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-3678
Practice Address - Country:US
Practice Address - Phone:414-649-6732
Practice Address - Fax:414-649-5840
Is Sole Proprietor?:No
Enumeration Date:2022-03-21
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program