Healthcare Provider Details

I. General information

NPI: 1013990332
Provider Name (Legal Business Name): WALLACE LLERA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2005
Last Update Date: 06/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401-55 W ALLEGHENY AVE
PHILADELPHIA PA
19133-3644
US

IV. Provider business mailing address

1412 FAIRMOUNT AVE
PHILADELPHIA PA
19130-2908
US

V. Phone/Fax

Practice location:
  • Phone: 215-291-2500
  • Fax: 215-291-2587
Mailing address:
  • Phone: 215-599-4851
  • Fax: 215-232-4093

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberMD038236L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: