Individual
MS. SANDRA LOUISE WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
50 ALESSANDRO PL, SUITE 360, PASADENA, CA 91105-3149
(626) 793-6133
(626) 793-6135
Mailing address
PO BOX 1449, BREA, CA 92822-1449
(714) 996-1633
(714) 996-9267
Taxonomy
Speciality
Code
Description
License number
State
207RI0200X
Infectious Disease Physician
Primary
G403910
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
00G403910
BLUE SHIELD
CA
05
—
00G403910
—
CA
01
—
110010430
RAILROAD RETIREMENT
—
Enumeration date
08/10/2006
Last updated
02/07/2011
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