Provider Demographics
NPI:1730128372
Name:WALLACE, KEVIN L (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:L
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 1:72 BRENTWOOD RD
Mailing Address - Street 2:
Mailing Address - City:CAPE ELIZABETH
Mailing Address - State:ME
Mailing Address - Zip Code:04107-2227
Mailing Address - Country:US
Mailing Address - Phone:602-769-1301
Mailing Address - Fax:207-221-1113
Practice Address - Street 1:925 E MCDOWELL RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2502
Practice Address - Country:US
Practice Address - Phone:602-239-2371
Practice Address - Fax:602-239-4138
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ233482083T0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083T0002XAllopathic & Osteopathic PhysiciansPreventive MedicineMedical Toxicology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ323923Medicaid
AZ323923Medicaid
74413Medicare ID - Type Unspecified