Healthcare Provider Details

I. General information

NPI: 1255867784
Provider Name (Legal Business Name): MATTHEW MALONE WALLACE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2017
Last Update Date: 09/24/2025
Certification Date: 09/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3829 GASKINS RD STE A
RICHMOND VA
23233-1437
US

IV. Provider business mailing address

3829 GASKINS RD STE A
RICHMOND VA
23233-1437
US

V. Phone/Fax

Practice location:
  • Phone: 804-282-8510
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number0101274476
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: