Provider Demographics
NPI:1790736122
Name:WALLENTINE, STEVEN L (MD)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:L
Last Name:WALLENTINE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 N 500 W
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3305
Mailing Address - Country:US
Mailing Address - Phone:801-354-8225
Mailing Address - Fax:801-418-0941
Practice Address - Street 1:1055 N 500 W
Practice Address - Street 2:SUITE 202
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3305
Practice Address - Country:US
Practice Address - Phone:801-374-2367
Practice Address - Fax:801-429-8015
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT60986311205207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT87028102800BOtherEMIA
UT870281028000Medicaid
UT88780OtherPEHP
UT933849OtherDMBA
UTP00345446OtherPALMETTO
UTI62333OtherUPIN
UT36-00187OtherUHC
UT107046686101OtherIHC
UT285195OtherALTIUS
UT6098631120000OtherBCBS
UT107046686101OtherIHC