Provider Demographics
NPI:1104359975
Name:WALLACE, SCOTT ROBERT
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:ROBERT
Last Name:WALLACE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 S 24TH AVE
Mailing Address - Street 2:
Mailing Address - City:EDINBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78539-6533
Mailing Address - Country:US
Mailing Address - Phone:956-289-7025
Mailing Address - Fax:956-513-0409
Practice Address - Street 1:103 N LOOP 499
Practice Address - Street 2:
Practice Address - City:HARLINGEN
Practice Address - State:TX
Practice Address - Zip Code:78550-2557
Practice Address - Country:US
Practice Address - Phone:956-289-7000
Practice Address - Fax:956-513-0409
Is Sole Proprietor?:No
Enumeration Date:2017-04-07
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXBP100597712084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX138708613Medicaid