Individual
DR. JONATHAN WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
4885 HOFFMAN BLVD, SUITE 400, HOFFMAN ESTATES, IL 60192-3726
(847) 255-9697
(847) 255-9697
Mailing address
4885 HOFFMAN BLVD, SUITE 400, HOFFMAN ESTATES, IL 60192-3726
(847) 255-9697
(847) 255-9697
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
036108563
IL
208600000X
Surgery Physician
Primary
036108563
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036108563
—
IL
Enumeration date
03/27/2006
Last updated
03/19/2021
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