Provider Demographics
NPI:1841299146
Name:WALLACE, MARC A (DO)
Entity type:Individual
Prefix:
First Name:MARC
Middle Name:A
Last Name:WALLACE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 PLATT DR
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15904-4305
Mailing Address - Country:US
Mailing Address - Phone:412-478-6416
Mailing Address - Fax:412-387-5010
Practice Address - Street 1:138 PLATT DR
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15904-4305
Practice Address - Country:US
Practice Address - Phone:412-478-6416
Practice Address - Fax:412-387-5010
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-19
Last Update Date:2025-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS00848L2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
H80483Medicare UPIN