Provider Demographics
NPI:1649243692
Name:WALLIS, KENNETH C (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:C
Last Name:WALLIS
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 1:1260 LAKE BLVD
Mailing Address - Street 2:SUITE #214
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-2614
Mailing Address - Country:US
Mailing Address - Phone:530-771-2308
Mailing Address - Fax:530-771-2309
Practice Address - Street 1:1260 LAKE BLVD
Practice Address - Street 2:SUITE #214
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-2614
Practice Address - Country:US
Practice Address - Phone:530-771-2308
Practice Address - Fax:530-771-2309
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC-419602084P0800X
UT8116741812052084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT107005564101OtherINTRMTN. HEALTH CARE
UT261795OtherDESERET MUTUAL
UT942938348WA1OtherEDUCATORS MUTUAL
UT107005564101OtherINTRMTN. HEALTH CARE
UTA37714Medicare ID - Type UnspecifiedMEDICARE ADVANTAGE PLANS