Provider Demographics
NPI:1588624282
Name:WALLACE, MAX LEE JR (MD)
Entity Type:Individual
Prefix:
First Name:MAX
Middle Name:LEE
Last Name:WALLACE
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 HART ST
Mailing Address - Street 2:SUITE B1
Mailing Address - City:NEW BRITAIN
Mailing Address - State:CT
Mailing Address - Zip Code:06052-1743
Mailing Address - Country:US
Mailing Address - Phone:860-229-2059
Mailing Address - Fax:860-229-8495
Practice Address - Street 1:40 HART ST
Practice Address - Street 2:SUITE B1
Practice Address - City:NEW BRITAIN
Practice Address - State:CT
Practice Address - Zip Code:06052-1743
Practice Address - Country:US
Practice Address - Phone:860-229-2059
Practice Address - Fax:860-229-8495
Is Sole Proprietor?:No
Enumeration Date:2006-03-25
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0233012085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT300117749OtherRAILROAD MEDICARE
CT010023301CT13OtherANTHEM BC/BS
CT001233014Medicaid
CT010026126CT12OtherANTHEM BC/BS
CT010026126CT03OtherANTHEM BC/BS
CT010026126CT14OtherANTHEM BC/BS
CT1588624282Medicaid
CT010026126CT04OtherANTHEM BC/BS
CT010026126CT07OtherANTHEM BC/BS
CT300023202OtherRAILROAD MEDICARE
CT300106345OtherRAILROAD MEDICARE
CT010023301CT13OtherANTHEM BC/BS
CT010026126CT07OtherANTHEM BC/BS
CT300000203Medicare ID - Type Unspecified
CTD77026Medicare UPIN
CT300000927Medicare PIN
CT300106345OtherRAILROAD MEDICARE
CT010026126CT04OtherANTHEM BC/BS