Healthcare Provider Details

I. General information

NPI: 1275809899
Provider Name (Legal Business Name): SCOTT ANDREW WALLACE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2012
Last Update Date: 10/03/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8901 WISCONSIN AVE BLDG 85T
BETHESDA MD
20889-0004
US

IV. Provider business mailing address

8901 WISCONSIN AVE BLDG 85T
BETHESDA MD
20889-0004
US

V. Phone/Fax

Practice location:
  • Phone: 301-295-0786
  • Fax:
Mailing address:
  • Phone: 301-295-0786
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0500X
TaxonomyPreventive Medicine/Occupational Environmental Medicine Physician
License NumberD76451
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: