Basic Information
| Provider Information | |||||||||
| NPI: | 1235140930 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALLACE | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | LOUISE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1449 | ||||||||
| Address2: | |||||||||
| City: | BREA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928221449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7149961633 | ||||||||
| FaxNumber: | 7149969267 | ||||||||
| Practice Location | |||||||||
| Address1: | 50 ALESSANDRO PL | ||||||||
| Address2: | SUITE 360 | ||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911053149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6267936133 | ||||||||
| FaxNumber: | 6267936135 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2006 | ||||||||
| LastUpdateDate: | 02/07/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | G403910 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 00G403910 | 05 | CA | MEDICAID | 110010430 | 01 | RAILROAD RETIREMENT | OTHER | 00G403910 | 01 | CA | BLUE SHIELD | OTHER |