Provider Demographics
NPI:1437181153
Name:WALLACE, RAYMOND B (DO)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:B
Last Name:WALLACE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 CORAL DR
Mailing Address - Street 2:STE A
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-1483
Mailing Address - Country:US
Mailing Address - Phone:414-290-6720
Mailing Address - Fax:414-290-6755
Practice Address - Street 1:111 E WISCONSIN AVE
Practice Address - Street 2:SUITE 2000
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-4815
Practice Address - Country:US
Practice Address - Phone:414-290-6720
Practice Address - Fax:414-290-6755
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI44478-021207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI930122235OtherMEDICARE RAILROAD
WI43500600Medicaid
G23677Medicare UPIN
WI930122235OtherMEDICARE RAILROAD
WI43500600Medicaid