Provider Demographics
NPI:1215992334
Name:WALLACE, EMMETT LEE (DO)
Entity type:Individual
Prefix:
First Name:EMMETT
Middle Name:LEE
Last Name:WALLACE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1019 BROADLAWN AVENUE
Mailing Address - Street 2:
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722
Mailing Address - Country:US
Mailing Address - Phone:563-359-1181
Mailing Address - Fax:563-386-3177
Practice Address - Street 1:1019 BROADLAWN AVENUE
Practice Address - Street 2:
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722
Practice Address - Country:US
Practice Address - Phone:563-359-1181
Practice Address - Fax:563-386-3177
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-20
Last Update Date:2011-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01133207Q00000X
MO27754207Q00000X
IL03652892207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0047902Medicaid
0158642OtherBCBS
0158642OtherBCBS
IAD46482Medicare UPIN