Provider Demographics
NPI:1063499267
Name:WALLACE, GRAHAM WILSON (MD)
Entity type:Individual
Prefix:DR
First Name:GRAHAM
Middle Name:WILSON
Last Name:WALLACE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:777 BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80204-4597
Mailing Address - Country:US
Mailing Address - Phone:303-643-6494
Mailing Address - Fax:303-602-4168
Practice Address - Street 1:777 BANNOCK ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80204-4597
Practice Address - Country:US
Practice Address - Phone:303-643-6494
Practice Address - Fax:303-602-4168
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01051128A207Q00000X, 2085R0202X
CAC1422172085R0202X
CODR.00682642085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine