Provider Demographics
NPI:1154434488
Name:WALLACE, ERIC (MD)
Entity type:Individual
Prefix:DR
First Name:ERIC
Middle Name:
Last Name:WALLACE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:143 LONGWATER DR
Mailing Address - Street 2:
Mailing Address - City:NORWELL
Mailing Address - State:MA
Mailing Address - Zip Code:02061-1683
Mailing Address - Country:US
Mailing Address - Phone:781-878-5200
Mailing Address - Fax:781-878-6750
Practice Address - Street 1:143 LONGWATER DR
Practice Address - Street 2:
Practice Address - City:NORWELL
Practice Address - State:MA
Practice Address - Zip Code:02061-1683
Practice Address - Country:US
Practice Address - Phone:781-878-5200
Practice Address - Fax:781-878-6750
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA243033207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
04-2297845OtherUNITED HEALTH CARE
MA1154434488OtherTMP
1154434488OtherTUFTS HEALTH PLAN
MA042297845OtherMULTI-PLAN
MA3748610OtherCIGNA
MAAA387771OtherHARVARD PILGRIM
MASS0165OtherBCBSMA
MA1154434488OtherNEIGHBORHOOD HEALTH PLAN
MA1154434488Medicaid
042297845OtherTRICARE
042297845OtherHCVM
MA7087919OtherAETNA
1154434488OtherFALLON HEALTH CARE