Provider Demographics
NPI:1518943604
Name:WALLACE, BRETT E (MD)
Entity Type:Individual
Prefix:DR
First Name:BRETT
Middle Name:E
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 1:2660 SW 3RD ST
Mailing Address - Street 2:
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66606-2442
Mailing Address - Country:US
Mailing Address - Phone:785-270-8880
Mailing Address - Fax:785-270-4589
Practice Address - Street 1:2660 SW 3RD ST
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66606
Practice Address - Country:US
Practice Address - Phone:785-270-8880
Practice Address - Fax:785-270-4589
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2018-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-21849207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100205880AMedicaid
KS068002052OtherMEDICARE PTAN
KS100205880BMedicaid
KS100205880AMedicaid
KS1932161320Medicare NSC