Provider Demographics
NPI:1477592210
Name:WALLACE, DARRYL (MD)
Entity Type:Individual
Prefix:
First Name:DARRYL
Middle Name:
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:PO BOX 504407
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-4407
Mailing Address - Country:US
Mailing Address - Phone:816-932-7947
Mailing Address - Fax:816-932-7957
Practice Address - Street 1:4321 WASHINGTON ST
Practice Address - Street 2:SUITE 4000
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64111-5961
Practice Address - Country:US
Practice Address - Phone:816-932-4549
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS415529207VX0201X
MOR5048207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO201094802Medicaid
33690OtherHEALTHCARE USA
09381035OtherBCBS OF KC
910000367OtherRAILROAD MEDICARE
4602518OtherAETNA
7400202OtherUHC
09381035OtherBCBS OF KC
7400202OtherUHC
MOW19000166Medicare PIN
KSW19A00063Medicare PIN