Provider Demographics
NPI:1629258322
Name:WALLACE, PHILIP C (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:C
Last Name:WALLACE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:2115 NE WYATT CT
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-7678
Mailing Address - Country:US
Mailing Address - Phone:541-323-6280
Mailing Address - Fax:541-323-6288
Practice Address - Street 1:2115 NE WYATT CT.
Practice Address - Street 2:101
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-6324
Practice Address - Country:US
Practice Address - Phone:541-323-6280
Practice Address - Fax:541-323-6288
Is Sole Proprietor?:No
Enumeration Date:2007-11-09
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ORMD152056208100000X
TXP1432208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation