Provider Demographics
NPI:1073524252
Name:SARVER, WALLACE B (DO)
Entity Type:Individual
Prefix:
First Name:WALLACE
Middle Name:B
Last Name:SARVER
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 1:1650 E STACY RD STE 160
Mailing Address - Street 2:
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75002-8778
Mailing Address - Country:US
Mailing Address - Phone:214-726-9098
Mailing Address - Fax:972-727-0842
Practice Address - Street 1:1650 E STACY RD STE 160
Practice Address - Street 2:
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75002-8778
Practice Address - Country:US
Practice Address - Phone:214-726-9098
Practice Address - Fax:972-727-0842
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI44144207Q00000X
TXN1439207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX347869501Medicaid
TX266886YZNAOtherMEDICARE
TX266886ZMCYOtherMEDICARE