1255642930 NPI number — JANIKA INEZ WALLACE D.O.

Table of content: JANIKA INEZ WALLACE D.O. (NPI 1255642930)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255642930 NPI number — JANIKA INEZ WALLACE D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALLACE
Provider First Name:
JANIKA
Provider Middle Name:
INEZ
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255642930
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/07/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
104 E CECIL AVE
Provider Second Line Business Mailing Address:
1ST FLOOR
Provider Business Mailing Address City Name:
NORTH EAST
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21901-4016
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-287-7021
Provider Business Mailing Address Fax Number:
410-287-7067

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
104 E CECIL AVE
Provider Second Line Business Practice Location Address:
1ST FLOOR
Provider Business Practice Location Address City Name:
NORTH EAST
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21901-4016
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-287-7021
Provider Business Practice Location Address Fax Number:
410-287-7067
Provider Enumeration Date:
06/28/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 25MB09205500 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: H0075972 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 301409Y2B . This is a "MEDICARE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".