Provider Demographics
NPI:1063419000
Name:WALLACE, CARMEL JR (MD)
Entity type:Individual
Prefix:
First Name:CARMEL
Middle Name:
Last Name:WALLACE
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:138 LEADER AVE, OFFICE 241
Mailing Address - Street 2:UNIVERSITY OF KENTUCKY, DEPARTMENT OF PEDIATRICS
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40506-9983
Mailing Address - Country:US
Mailing Address - Phone:859-323-1432
Mailing Address - Fax:859-323-3499
Practice Address - Street 1:138 LEADER AVE, OFFICE 241
Practice Address - Street 2:UNIVERSITY OF KENTUCKY, DEPARTMENT OF PEDIATRICS
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40506-9983
Practice Address - Country:US
Practice Address - Phone:859-323-1432
Practice Address - Fax:859-323-3499
Is Sole Proprietor?:No
Enumeration Date:2005-07-06
Last Update Date:2015-12-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY18479208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64184799Medicaid
KY64184799Medicaid
C69804Medicare UPIN