NPIMap

Individual provider Active NPI

Eric Wallace, MD

  • Diagnostic Radiology Physician
  • Ventura, CA
National Provider Identifier
1578502191
Registry record updated Nov 14, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
Diagnostic Radiology PhysicianTaxonomy code 2085R0202X
License
A85195 Issued in CA
Practice address
168 N Brent St
Suite 402
Ventura, CA 93003-2817
Phone
(888) 234-0004
Fax
(805) 641-3965
NPI assigned
Jun 6, 2006
Last updated
Nov 14, 2017By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Nov 14, 2017

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

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Diagnostic Radiology Physician 2085R0202X A85195 CA Primary

Addresses

Primary practice location

168 N Brent St
Suite 402
Ventura, CA 93003-2817

Mailing address

4100 Guardian St
Ste 205
Simi Valley, CA 93063-6721
Phone (855) 504-4544

Other identifiers 2

IdentifierTypeStateIssuer
00A851950OtherCABLUESHIELD OF CA
00A851950MedicaidCA

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA, WA, AK3 enrollments
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 3

Enrollment IDStateProvider typePAC IDDetails
I20050608001128 CA Practitioner - Diagnostic Radiology 3577506690 Reassigns benefits to 1 organization
I20210317001829 WA Practitioner - Diagnostic Radiology 3577506690 Reassigns benefits to 8 organizations
I20210323002609 AK Practitioner - Diagnostic Radiology 3577506690 Reassigns benefits to 8 organizations

Care Compare profile

Medicare Care Compare
Specialty
Diagnostic Radiology
Education
Loma Linda University School of Medicine, 1999
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Skagit Digital Imaging LLCGroup PAC ID 4486543204, 29 clinicians
Bellingham Advanced Medical Imaging LLCGroup PAC ID 9739446824, 27 clinicians
Skagit Radiology Inc P SGroup PAC ID 7113815218, 39 clinicians
Fairbanks Medical Imaging LLCGroup PAC ID 4082894407, 28 clinicians
North Star Medical Imaging PLLCGroup PAC ID 7214005099, 30 clinicians

Practice addresses (Care Compare)

101 N Main St
Coupeville, WA 98239-3413

1211 24TH St
Anacortes, WA 98221-2562
Phone (360) 678-5151

1320 E Division St
Mount Vernon, WA 98274-4133
Phone (360) 424-6161

1344 King St
Suite 101
Bellingham, WA 98229-6215
Phone (360) 424-6161

1415 E Kincaid St
Mount Vernon, WA 98274-4126
Phone (360) 424-6161

2310 Peger Rd
Suite 102
Fairbanks, AK 99709-5305
Phone (360) 678-5151

2340 Chief John Dr
Fairbanks, AK 99709-2814
Phone (360) 424-6161

250 Hospital PL
Soldotna, AK 99669-7559
Phone (360) 424-6161

834 Sheridan St
Port Townsend, WA 98368-2443
Phone (360) 385-2200

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
266916NYMDLicensed Practical Nurse

Practice roles

OrganizationSpecialtyStatusNew patients
Whidbey Island Public Hospital District Diagnostic Radiology CurrentSince Apr 1, 2021 Accepting new patients
North Star Medical Imaging PLLC Diagnostic Radiology CurrentSince Apr 1, 2021 Accepting new patients
Jefferson County Public Hospital District No 2 CurrentSince Nov 1, 2022 Accepting new patients
Iliuliuk Family and Health Services Inc CurrentSince May 1, 2023 Accepting new patients
Fairbanks Medical Imaging LLC Diagnostic Radiology CurrentSince Apr 1, 2021 Accepting new patients
Whidbey Island Public Hospital District CurrentSince Apr 1, 2021 Accepting new patients
Bellingham Advanced Medical Imaging LLC Diagnostic Radiology CurrentSince Apr 1, 2021 Accepting new patients
Jefferson County Public Hospital District No 2 CurrentSince Nov 1, 2022 Accepting new patients
Skagit Radiology Inc P S Diagnostic Radiology CurrentSince Apr 1, 2021 Accepting new patients
Community Imaging Medical Group Inc Diagnostic Radiology Past Accepting new patients
Iliuliuk Family &Health Services, Inc. Past Accepting new patients
California Managed Imaging Medical Group, Inc Diagnostic Radiology Past Accepting new patients
Pueblo Radiology Medical Group Inc Diagnostic Radiology Past Accepting new patients

Locations

2310 Peger Rd
Ste 102
Fairbanks, AK 99709

250 Hospital Pl
Soldotna, AK 99669
Phone (907) 714-4404

1211 24th St
Anacortes, WA 98221
Phone (360) 293-3181

1344 King St
Ste 101
Bellingham, WA 98229
Phone (360) 676-6393

101 N Main St
Coupeville, WA 98239
Phone (360) 678-7656

1320 E Division St
Mount Vernon, WA 98274
Phone (360) 424-9607

1415 E Kincaid St
Mount Vernon, WA 98274
Phone (360) 416-5750

1200 W Sims Way
Ste C
Port Townsend, WA 98368
Phone (360) 385-6297

834 Sheridan St
Port Townsend, WA 98368
Phone (360) 344-0400

Organizations & group practices 15

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

View all 15

Hospital & facility affiliations 28

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

View all 28

NPI Registry JSON

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

{
    "created_epoch": "1149552000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1510617600000",
    "number": "1578502191",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4100 GUARDIAN ST",
            "address_2": "STE 205",
            "city": "SIMI VALLEY",
            "state": "CA",
            "postal_code": "930636721",
            "telephone_number": "855-504-4544",
            "fax_number": "855-577-2018"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "168 N BRENT ST",
            "address_2": "SUITE 402",
            "city": "VENTURA",
            "state": "CA",
            "postal_code": "930032817",
            "telephone_number": "888-234-0004",
            "fax_number": "805-641-3965"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "ERIC",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-06-06",
        "last_updated": "2017-11-14",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "2085R0202X",
            "taxonomy_group": "",
            "desc": "Radiology, Diagnostic Radiology",
            "state": "CA",
            "license": "A85195",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUESHIELD OF CA",
            "identifier": "00A851950",
            "state": "CA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "00A851950",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Ventura, CA

Sources for this page

Verify at the official NPI Registry.