Provider Demographics
NPI:1285924696
Name:WALLACE-JUEDES, WENDELL DAMYEON (DPM)
Entity type:Individual
Prefix:DR
First Name:WENDELL
Middle Name:DAMYEON
Last Name:WALLACE-JUEDES
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:386 MERRIMACK ST
Mailing Address - Street 2:SUITE 1B
Mailing Address - City:METHUEN
Mailing Address - State:MA
Mailing Address - Zip Code:01844-5802
Mailing Address - Country:US
Mailing Address - Phone:978-682-0382
Mailing Address - Fax:978-975-3585
Practice Address - Street 1:386 MERRIMACK ST
Practice Address - Street 2:SUITE 1B
Practice Address - City:METHUEN
Practice Address - State:MA
Practice Address - Zip Code:01844-5802
Practice Address - Country:US
Practice Address - Phone:978-682-0382
Practice Address - Fax:978-975-3585
Is Sole Proprietor?:No
Enumeration Date:2011-04-19
Last Update Date:2015-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2407213E00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist