Provider Demographics
NPI:1487090098
Name:SCOTT C. WALLACE, MD
Entity type:Organization
Organization Name:SCOTT C. WALLACE, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:C
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-495-0971
Mailing Address - Street 1:8525 GIBBS DR
Mailing Address - Street 2:SUITE 208
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-1755
Mailing Address - Country:US
Mailing Address - Phone:858-495-0971
Mailing Address - Fax:858-495-0991
Practice Address - Street 1:8525 GIBBS DR
Practice Address - Street 2:SUITE 208
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1755
Practice Address - Country:US
Practice Address - Phone:858-495-0971
Practice Address - Fax:858-495-0991
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-22
Last Update Date:2013-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA115766207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty