Provider Demographics
NPI:1932193604
Name:WALLACE, DAVID (DO)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
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 1:738 GOLDEN PHEASANT DR
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-8454
Mailing Address - Country:US
Mailing Address - Phone:801-403-7980
Mailing Address - Fax:
Practice Address - Street 1:738 GOLDEN PHEASANT DR
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-8454
Practice Address - Country:US
Practice Address - Phone:801-403-7980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT272263-1205207L00000X
MI5101010132207L00000X
MS15448207L00000X
IDO-168207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD4253Medicaid
UTF07597Medicare UPIN