Basic Information
| Provider Information | |||||||||
| NPI: | 1568658243 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALLACE | ||||||||
| FirstName: | ERIC | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 W IRONWOOD DR | ||||||||
| Address2: | 320 | ||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838142656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086255250 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 700 W IRONWOOD DR | ||||||||
| Address2: | 320 | ||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838142656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086255250 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2007 | ||||||||
| LastUpdateDate: | 12/31/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0011X | OP60505950 | WA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207R00000X | 2007-014326 | NC | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 03263 | KY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | O0839 | ID | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.