Healthcare Provider Details

I. General information

NPI: 1558893503
Provider Name (Legal Business Name): EMMA WALLACE MD/PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2017
Last Update Date: 04/11/2022
Certification Date: 04/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 E 210TH ST
BRONX NY
10467-2401
US

IV. Provider business mailing address

43 WESTMINSTER AVE
BERGENFIELD NJ
07621-3913
US

V. Phone/Fax

Practice location:
  • Phone: 718-430-3166
  • Fax:
Mailing address:
  • Phone: 201-387-1957
  • Fax: 201-351-0656

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number312463
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084V0102X
TaxonomyVascular Neurology Physician
License Number312463
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: