Healthcare Provider Details

I. General information

NPI: 1235140930
Provider Name (Legal Business Name): SANDRA LOUISE WALLACE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 02/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 ALESSANDRO PL SUITE 360
PASADENA CA
91105-3149
US

IV. Provider business mailing address

PO BOX 1449
BREA CA
92822-1449
US

V. Phone/Fax

Practice location:
  • Phone: 626-793-6133
  • Fax: 626-793-6135
Mailing address:
  • Phone: 714-996-1633
  • Fax: 714-996-9267

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberG403910
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: