Provider Demographics
NPI:1528293883
Name:WALLACE, ERICA RENEE (DO)
Entity type:Individual
Prefix:DR
First Name:ERICA
Middle Name:RENEE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E WENDOVER AVE
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-1229
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4023 GUILFORD COLLEGE RD
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27407-8052
Practice Address - Country:US
Practice Address - Phone:336-890-2040
Practice Address - Fax:336-890-2099
Is Sole Proprietor?:No
Enumeration Date:2009-05-15
Last Update Date:2025-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2012-00866207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNC7155AOtherMEDICARE PTAN
NC5920661Medicaid