Wallace, Derrick I

Wallace, Derrick I is an sole proprietor health care provider with primary practice located at 187 Washington Ave Suite 2I, Nutley NJ 07110-3935. He recently has only one registered license in Allopathic & Osteopathic Physicians / Otolaryngology, which is considered as his primary health care specialty. Wallace, Derrick I can be contacted via phone (973) 235-0090.

Contact Information

Primary practice address
187 Washington Ave Suite 2I Nutley NJ 07110-3935
Phone: (973) 235-0090
Fax: (973) 235-0090
Website:
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Health care specialties

SpecialtyCodeLicense #State
Allopathic & Osteopathic Physicians / Otolaryngology 207Y00000X 208988 New York
Allopathic & Osteopathic Physicians / Otolaryngology 207Y00000X 25MA08175200 New Jersey

Profile Details

NPI number 1114900362
LBN Legal business name Wallace, Derrick I
Credentials Doctor of Medicine (MD)
Entity Individual
Sole proprietor 1 Yes
Enumeration date Nov 22nd, 2005
Last updated Nov 29th, 2011 - about 15 years ago

1 A sole proprietor/sole proprietorship is an individual, and in that capacity, is qualified for a solitary NPI number. The sole proprietor have to apply for the NPI number using his or her own particular Social Security Number (SSN), instead of Employer Identification Number (EIN) regardless of whether he/she has an EIN.

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Identifiers

StateTypeNumberIssuer
All States NPI 1114900362 NPPES
New York MEDICAID 02237176

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