1285924696 NPI number — DR. WENDELL DAMYEON WALLACE-JUEDES DPM

Table of content: ANDREW MYONG KIM M.D. (NPI 1689608051)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285924696 NPI number — DR. WENDELL DAMYEON WALLACE-JUEDES DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALLACE-JUEDES
Provider First Name:
WENDELL
Provider Middle Name:
DAMYEON
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
M

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:
1285924696
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/10/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
386 MERRIMACK ST
Provider Second Line Business Mailing Address:
SUITE 1B
Provider Business Mailing Address City Name:
METHUEN
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01844-5802
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
978-682-0382
Provider Business Mailing Address Fax Number:
978-975-3585

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
386 MERRIMACK ST
Provider Second Line Business Practice Location Address:
SUITE 1B
Provider Business Practice Location Address City Name:
METHUEN
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01844-5802
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-682-0382
Provider Business Practice Location Address Fax Number:
978-975-3585
Provider Enumeration Date:
04/19/2011

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: 213E00000X , with the licence number:  2407 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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