Provider Demographics
NPI:1417996232
Name:WALLACE, DAVID LEE (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:LEE
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 1:330 NORTH WABASH AVE.
Mailing Address - Street 2:SUITE G20
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-2600
Mailing Address - Country:US
Mailing Address - Phone:765-660-6411
Mailing Address - Fax:765-651-7313
Practice Address - Street 1:441 N WABASH AVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952-2612
Practice Address - Country:US
Practice Address - Phone:765-660-7600
Practice Address - Fax:765-651-7313
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01027186207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100066360Medicaid
IN000000530919OtherANTHEM
IN100066360Medicaid
B95774Medicare UPIN