Provider Demographics
NPI:1306945829
Name:WALLACE, MATHEW CARY (MD)
Entity type:Individual
Prefix:DR
First Name:MATHEW
Middle Name:CARY
Last Name:WALLACE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MATHEW
Other - Middle Name:CARY
Other - Last Name:WALLACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4228 LOMAC ST STE 2
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36106-2929
Mailing Address - Country:US
Mailing Address - Phone:919-928-2351
Mailing Address - Fax:
Practice Address - Street 1:4228 LOMAC ST STE 2
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36106-2929
Practice Address - Country:US
Practice Address - Phone:919-928-2351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD.292022084P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P2900XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05273575Medicaid
MS605725800OtherUS DEPARTMENT OF LABOR
MS605725800OtherUS DEPARTMENT OF LABOR
MS605725800OtherUS DEPARTMENT OF LABOR
MS$$$$$$$$$COtherBLUE CROSS