Provider Demographics
NPI:1356329114
Name:WALLACE, MATTHEW K (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:K
Last Name:WALLACE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 W 5TH AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99204-2715
Mailing Address - Country:US
Mailing Address - Phone:509-344-2663
Mailing Address - Fax:509-624-9179
Practice Address - Street 1:212 E CENTRAL AVE STE 140
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99208-6289
Practice Address - Country:US
Practice Address - Phone:509-465-1300
Practice Address - Fax:509-465-1313
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN47815207X00000X
WAMD60144423207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN265453900Medicaid
WA2007981Medicaid
I40638Medicare UPIN
G319213900Medicare PIN
WA2007981Medicaid
MN200002386Medicare ID - Type Unspecified