Provider Demographics
NPI:1033186911
Name:WALLACE, DEBRA J (MD)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:J
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1079
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:KY
Mailing Address - Zip Code:42419-1079
Mailing Address - Country:US
Mailing Address - Phone:270-827-0353
Mailing Address - Fax:270-827-4966
Practice Address - Street 1:1284 US HIGHWAY 60 W
Practice Address - Street 2:
Practice Address - City:MORGANFIELD
Practice Address - State:KY
Practice Address - Zip Code:42437-6236
Practice Address - Country:US
Practice Address - Phone:270-389-2323
Practice Address - Fax:270-389-0526
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY22551207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64225519Medicaid
KY50002853Medicaid
KY000000259190OtherANTHEM BC & BS
KY64225519Medicaid
KY50002853Medicaid
KY0744401Medicare ID - Type Unspecified