Provider Demographics
NPI:1679550875
Name:WALLACE, WELDON (MD)
Entity Type:Individual
Prefix:
First Name:WELDON
Middle Name:
Last Name:WALLACE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1260 EKHART ST NE
Mailing Address - Street 2:112
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-1372
Mailing Address - Country:US
Mailing Address - Phone:616-356-5202
Mailing Address - Fax:616-458-9845
Practice Address - Street 1:1260 EKHART ST NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-1372
Practice Address - Country:US
Practice Address - Phone:616-356-5202
Practice Address - Fax:616-458-9845
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301085136207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4752504Medicaid
MI4752504Medicaid