Provider Demographics
NPI:1407812407
Name:WALLACE, BILLI S (MD)
Entity Type:Individual
Prefix:DR
First Name:BILLI
Middle Name:S
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 1:800 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-5275
Mailing Address - Country:US
Mailing Address - Phone:573-814-6000
Mailing Address - Fax:
Practice Address - Street 1:800 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201
Practice Address - Country:US
Practice Address - Phone:573-814-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0431738207W00000X
OK22899207W00000X
MO2006009608207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00318928Medicare PIN
KS405E569EMedicare PIN
MO405E569DMedicare PIN
MO405E569AMedicare PIN
I32347Medicare UPIN
MO405E569HMedicare PIN