Provider Demographics
NPI:1699759191
Name:NEVYAS-WALLACE, ANITA (MD)
Entity type:Individual
Prefix:DR
First Name:ANITA
Middle Name:
Last Name:NEVYAS-WALLACE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 E CITY AVE
Mailing Address - Street 2:2 BALA PLAZA
Mailing Address - City:BALA CYNWYD
Mailing Address - State:PA
Mailing Address - Zip Code:19004-1501
Mailing Address - Country:US
Mailing Address - Phone:610-668-1192
Mailing Address - Fax:610-668-1509
Practice Address - Street 1:333 E CITY AVE
Practice Address - Street 2:2 BALA PLAZA
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:2005-11-30
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD031809E174400000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0703757000OtherAMERIHEALTH HMO
PA0110114000OtherKEYSTONE HEALTH PLAN
PA0110114000OtherINDEPENDENCE BLUE CROSS
PA0004407700OtherAETNA PPO
PA0012162020001Medicaid
NJ1054207OtherCIGNA HEALTH PLAN
PA31236GOtherKEYSTONE MERCY HP
PA10240MD031809EOtherHEALTH PARTNERS
NJ483140OtherAETNA HMO
PA510550OtherPA BLUE SHIELD
PA483038OtherAETNA HMO
PACA2279OtherMEDICARE TYPE UNSPECIFIED
NJ6211101Medicaid
NJ760539OtherPA BLUE SHIELD
PA912202OtherUNITED HEALTHCARE
NJ0703757000OtherINDEPENDENCE BLUE CROSS
PA180020274OtherMEDICARE TYPE UNSPECIFIED
NJ483140OtherAETNA HMO
NJ760539OtherPA BLUE SHIELD
PA510550OtherPA BLUE SHIELD
NJ6211101Medicaid