Individual
ERIC WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
168 N BRENT ST, SUITE 402, VENTURA, CA 93003-2817
(888) 234-0004
(805) 641-3965
Mailing address
4100 GUARDIAN ST, STE 205, SIMI VALLEY, CA 93063-6721
(855) 504-4544
(855) 577-2018
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
Primary
A85195
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
00A851950
BLUESHIELD OF CA
CA
05
—
00A851950
—
CA
Enumeration date
06/06/2006
Last updated
11/14/2017
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