Provider Demographics
NPI:1861426462
Name:WALLACE, JOHN A (DPM)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:WALLACE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 W MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:MERCHANTVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08109-1822
Mailing Address - Country:US
Mailing Address - Phone:856-665-1180
Mailing Address - Fax:856-665-5537
Practice Address - Street 1:702 W MAPLE AVE
Practice Address - Street 2:
Practice Address - City:MERCHANTVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08109-1822
Practice Address - Country:US
Practice Address - Phone:856-665-1180
Practice Address - Fax:856-665-5537
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMD00151900213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6574009Medicaid
NJ0425672000OtherAMERIHEALTH
NJ082365Medicare ID - Type Unspecified
NJ0425672000OtherAMERIHEALTH