Provider Demographics
NPI:1740241835
Name:WALLACE, CYNTHIA CALBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:CYNTHIA
Middle Name:CALBERT
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 SE BLUE PKWY STE 270B
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64063-1029
Mailing Address - Country:US
Mailing Address - Phone:816-333-5005
Mailing Address - Fax:816-333-6351
Practice Address - Street 1:4320 WORNALL RD
Practice Address - Street 2:SUITE 720
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64111-5941
Practice Address - Country:US
Practice Address - Phone:816-531-2111
Practice Address - Fax:816-531-6025
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR1G97207V00000X, 207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOD93612Medicare UPIN