Provider Demographics
NPI:1306868534
Name:WALLACE, KACEY L (DO)
Entity type:Individual
Prefix:
First Name:KACEY
Middle Name:L
Last Name:WALLACE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 W CHOCTAW AVE STE 9
Mailing Address - Street 2:
Mailing Address - City:CHICKASHA
Mailing Address - State:OK
Mailing Address - Zip Code:73018
Mailing Address - Country:US
Mailing Address - Phone:405-544-2940
Mailing Address - Fax:405-337-9632
Practice Address - Street 1:1000 W CHOCTAW AVE STE 9
Practice Address - Street 2:
Practice Address - City:CHICKASHA
Practice Address - State:OK
Practice Address - Zip Code:73018
Practice Address - Country:US
Practice Address - Phone:405-544-2940
Practice Address - Fax:405-337-9632
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2023-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4339207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKP00331218OtherMEDICARE RAIL ROAD
OK200077860AMedicaid
OKOKAAA2225Medicare PIN
OK410233ZN2YMedicare PIN