Healthcare Provider Details

I. General information

NPI: 1861426462
Provider Name (Legal Business Name): JOHN A. WALLACE DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

702 W MAPLE AVE
MERCHANTVILLE NJ
08109-1822
US

IV. Provider business mailing address

702 W MAPLE AVE
MERCHANTVILLE NJ
08109-1822
US

V. Phone/Fax

Practice location:
  • Phone: 856-665-1180
  • Fax: 856-665-5537
Mailing address:
  • Phone: 856-665-1180
  • Fax: 856-665-5537

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License NumberMD00151900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: