Provider Demographics
NPI:1386753887
Name:WALLACE, SHERRIE S (DPM)
Entity type:Individual
Prefix:DR
First Name:SHERRIE
Middle Name:S
Last Name:WALLACE
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1485 S HAWKINS AVE
Mailing Address - Street 2:SUITE 159
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44320-3473
Mailing Address - Country:US
Mailing Address - Phone:330-798-5555
Mailing Address - Fax:330-798-5525
Practice Address - Street 1:1485 S HAWKINS AVE
Practice Address - Street 2:SUITE 159
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44320-3473
Practice Address - Country:US
Practice Address - Phone:330-798-5555
Practice Address - Fax:330-798-5525
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36002951213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0382974Medicaid
OH0382974Medicaid
OH0815421Medicare ID - Type Unspecified