Individual
DERRICK I WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
187 WASHINGTON AVE, SUITE 2I, NUTLEY, NJ 07110-3935
(973) 235-0090
(973) 235-0090
Mailing address
187 WASHINTON AVE, SUITE 2I, NUTLEY, NJ 07110-1980
(973) 235-0090
(973) 842-0830
Taxonomy
Speciality
Code
Description
License number
State
207Y00000X
Otolaryngology Physician
208988
NY
207Y00000X
Otolaryngology Physician
Primary
25MA08175200
NJ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
02237176
—
NY
Enumeration date
11/22/2005
Last updated
11/29/2011
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