Provider Demographics
NPI:1548279706
Name:WALLACE, AFRICA F (MD)
Entity type:Individual
Prefix:DR
First Name:AFRICA
Middle Name:F
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 CAPITAL WAY STE 356
Mailing Address - Street 2:
Mailing Address - City:PENNINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08534-2521
Mailing Address - Country:US
Mailing Address - Phone:609-815-7829
Mailing Address - Fax:
Practice Address - Street 1:2 CAPITAL WAY STE 356
Practice Address - Street 2:
Practice Address - City:PENNINGTON
Practice Address - State:NJ
Practice Address - Zip Code:08534-2521
Practice Address - Country:US
Practice Address - Phone:609-537-6000
Practice Address - Fax:609-537-6002
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD427591208600000X, 208G00000X
GA070603208G00000X
NJ25MA10677300208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
1548279706Medicare NSC
GA202I788463Medicare PIN
GA003137567Medicaid