Provider Demographics
NPI:1316993124
Name:WALLACE, IRA B (MD)
Entity type:Individual
Prefix:
First Name:IRA
Middle Name:B
Last Name:WALLACE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:2 BALA PLAZA
Mailing Address - Street 2:333 E CITY AVENUE
Mailing Address - City:BALA CYNWYD
Mailing Address - State:PA
Mailing Address - Zip Code:19004-1501
Mailing Address - Country:US
Mailing Address - Phone:610-668-2777
Mailing Address - Fax:610-668-1509
Practice Address - Street 1:2 BALA PLAZA
Practice Address - Street 2:333 E CITY AVENUE
Practice Address - City:BALA CYNWYD
Practice Address - State:PA
Practice Address - Zip Code:19004-1501
Practice Address - Country:US
Practice Address - Phone:610-668-2777
Practice Address - Fax:610-668-1509
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2010-11-23
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Provider Licenses
StateLicense IDTaxonomies
PAMD032125E174400000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAE58127Medicare UPIN
PA76626Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER