Provider Demographics
NPI:1477707685
Name:WALLACE, J. MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:J.
Middle Name:MICHAEL
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 1:821 S 600 E
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-3507
Mailing Address - Country:US
Mailing Address - Phone:503-475-8549
Mailing Address - Fax:
Practice Address - Street 1:1528 LAIRD AVE
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84105-1730
Practice Address - Country:US
Practice Address - Phone:503-475-8549
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-14
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7471598-1205207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIMD13915OtherMEDICAL LICENSE