Individual
MATTHEW BREVARD WALLACE III
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
1200 SUNSET LN STE 2210, CULPEPER, VA 22701-3376
(540) 825-6100
(540) 825-1829
Mailing address
PO BOX 9007, CHARLOTTESVILLE, VA 22906-9007
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
0101025059
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
005624339
—
VA
Enumeration date
07/12/2006
Last updated
03/29/2013
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