Provider Demographics
NPI:1497791156
Name:ARNESON, WALLACE A JR (MD)
Entity Type:Individual
Prefix:
First Name:WALLACE
Middle Name:A
Last Name:ARNESON
Suffix:JR
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 1:5325 ELLIOTT DR
Mailing Address - Street 2:SUITE 104
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-8633
Mailing Address - Country:US
Mailing Address - Phone:734-712-8150
Mailing Address - Fax:734-712-8151
Practice Address - Street 1:5325 ELLIOTT DR
Practice Address - Street 2:SUITE 104
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-8633
Practice Address - Country:US
Practice Address - Phone:734-712-8150
Practice Address - Fax:734-712-8151
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2011-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301036634208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4146890-10Medicaid
0M88760013Medicare ID - Type Unspecified
A77691Medicare UPIN