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NPI Code Detail

MEDICARE: DR. OLUKEMI A WALLACE M.D.

MEDICARE: DR. OLUKEMI A WALLACE M.D.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1174400000XSpecialistA48240CA

General Provider Information

NPI Number : 1609804350
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. OLUKEMI A WALLACE M.D.
Provider Business Mailing Address
First Line : 15342 HAWTHORNE BLVD
Second Line : SUITE 102
City : LAWNDALE
State : CA
Zip : 90260-2152
Country : US
Telephone Number : 310-644-8400
Fax Number : 310-644-8424
Provider Business Practice Location Address
First Line : 2220 W MANCHESTER BLVD
Second Line :
City : INGLEWOOD
State : CA
Zip : 90305-2514
Country : US
Telephone Number : 310-644-8400
Fax Number : 310-644-8424
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/30/2006
Last Update Date : 08/14/2024

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