Provider Demographics
NPI:1992709489
Name:ESPER, WALLACE J (DO)
Entity type:Individual
Prefix:DR
First Name:WALLACE
Middle Name:J
Last Name:ESPER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:DR
Other - First Name:WALLACE
Other - Middle Name:J
Other - Last Name:ESPER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:3435 W LAKE RD
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16505-3661
Mailing Address - Country:US
Mailing Address - Phone:814-438-3854
Mailing Address - Fax:814-438-2253
Practice Address - Street 1:3435 W LAKE RD
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16505-3661
Practice Address - Country:US
Practice Address - Phone:814-438-3854
Practice Address - Fax:814-438-2253
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-13
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS008755L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0015389120005Medicaid
PA785672Medicare ID - Type Unspecified