Provider Demographics
NPI:1376532168
Name:WALLACE, DAVID W (MD MBA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:W
Last Name:WALLACE
Suffix:
Gender:M
Credentials:MD MBA
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:100 E LIBERTY ST STE 800
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1428
Mailing Address - Country:US
Mailing Address - Phone:502-633-3525
Mailing Address - Fax:502-633-8075
Practice Address - Street 1:515 HOSPITAL DR
Practice Address - Street 2:SUITE 1
Practice Address - City:SHELBYVILLE
Practice Address - State:KY
Practice Address - Zip Code:40065-1640
Practice Address - Country:US
Practice Address - Phone:502-633-3525
Practice Address - Fax:502-633-8075
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY22054207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
0100487OtherUHC
KYP00872496OtherRR MEDICARE
KY000000048268OtherANTHEM
KY64220544Medicaid
KYP400017516Medicare Oscar/Certification
KY000000048268OtherANTHEM
KY64220544Medicaid