Individual
DR. ANDREW BLAKE WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
510 S KINGSHIGHWAY BLVD, MALLINCKRODT INSTITUE OF RADIOLOGY, SAINT LOUIS, MO 63110-1016
(314) 362-2978
Mailing address
1025 MEDICAL CENTER DR, WILMINGTON, NC 28401-7354
(910) 762-3882
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
2014013932
MO
2085R0202X
Diagnostic Radiology Physician
Primary
2020-04583
NC
Other
Enumeration date
05/18/2013
Last updated
05/05/2021
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