| Doctor Name: | JOHN A. WALLACE |
| NPI Number: | 1861426462 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | DPM |
| License Number: | MD00151900 |
| Business Practice Address: | 702 W Maple Ave Merchantville, NJ - 081091822 |
| Business Phone Number: | 8566651180 |
| Business Fax Number: | 8566655537 |
| Mailing Address: | 702 W Maple Ave, MERCHANTVILLE |
| State: | NJ |
| Postal Code: | 081091822 |
| Phone Number: | 8566651180 |
| Fax Number: | 8566655537 |
| NPI Enumeration Date: | 07/10/2006 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 213EP1101X |
| License Number: | MD00151900 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | NJ |
| Taxonomy Type: | Podiatric Medicine & Surgery Service Providers |
| Taxonomy Classification: | Podiatrist |
| Taxonomy Specialization: | Primary Podiatric Medicine |
| Taxonomy Definition: | |