Provider Demographics
NPI:1194764647
Name:WALLACE, DIANE E (MD)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:E
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:E
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:608 UNION CHAPEL RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-9357
Mailing Address - Country:US
Mailing Address - Phone:260-498-2020
Mailing Address - Fax:260-498-2030
Practice Address - Street 1:1355 MARINERS DR
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:IN
Practice Address - Zip Code:46582-7145
Practice Address - Country:US
Practice Address - Phone:574-372-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01061919A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
J97944Medicare UPIN