Provider Demographics
NPI:1316926066
Name:WALLACE, JOHN SR (IDC)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:WALLACE
Suffix:SR
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 JONATHANS WAY
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-9153
Mailing Address - Country:US
Mailing Address - Phone:757-923-3793
Mailing Address - Fax:
Practice Address - Street 1:300 E MAIN ST
Practice Address - Street 2:SUITE 1000
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23510-1753
Practice Address - Country:US
Practice Address - Phone:757-628-4347
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman