Healthcare Provider Details

I. General information

NPI: 1396364402
Provider Name (Legal Business Name): DAVID CARTER WALLACE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2020
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18250 ROSCOE BLVD
NORTHRIDGE CA
91325-4226
US

IV. Provider business mailing address

700 ACKERMAN RD STE 2120
COLUMBUS OH
43202-1559
US

V. Phone/Fax

Practice location:
  • Phone: 818-796-2920
  • Fax:
Mailing address:
  • Phone: 614-293-4837
  • Fax: 614-293-3125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number20A25571
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: