Mario James Wallace, PT, DPT

Primary specialty

Orthopedic Physical TherapistTaxonomy code 2251X0800X

License

052204 Issued in NY

Practice address

235 W 75TH St
New York, NY 10023-0328

Phone

(646) 518-5559

NPI assigned

Apr 16, 2024

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in NY

Enrollment records 1

Specialty

Physical Therapist in Private Practice

Education

Other, 2024

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Spear Physical and Occupational Therapy, LLCGroup PAC ID 6901832112, 582 clinicians

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Spear Physical and Occupational Therapy, LLC

  • Physical Therapy Clinic/Center
  • New York, NY
  • NPI 1063454577

  Orthopedic

  Medicare reassignment Care Compare group NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1713225600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1713225600000",
    "number": "1043064009",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "16 DOGWOOD DR",
            "city": "MIDDLETOWN",
            "state": "NY",
            "postal_code": "109401802",
            "telephone_number": "845-956-3453"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "235 W 75TH ST",
            "city": "NEW YORK",
            "state": "NY",
            "postal_code": "100230328",
            "telephone_number": "646-518-5559"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "MARIO",
        "middle_name": "JAMES",
        "name_prefix": "Mr.",
        "credential": "PT, DPT",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2024-04-16",
        "last_updated": "2024-04-16",
        "certification_date": "2024-04-16",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "2251X0800X",
            "taxonomy_group": "",
            "desc": "Physical Therapist, Orthopedic",
            "state": "NY",
            "license": "052204",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Kisha Wallace
• Kyana Wallace, PA-C
• Laney Elizabeth Wallace, MPS, LCAT, ATR-BC
• Lauren Wallace
• Loretta Wallace
• Marisa I Wallace, DNP, FNP-BC
• Mark Edward Wallace, M.D.
• Matthew Alexander Wallace, P.A.
• Maureen Elizabeth Wallace, PH.D.
• Megan Wallace

• Orthopedic Physical Therapist in New York, NY
• Providers in New York, NY by specialty
• Orthopedic Physical Therapist in New York

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 16, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.