Provider Demographics
NPI:1811030372
Name:WALLIS, MLOU F (MD)
Entity Type:Individual
Prefix:
First Name:MLOU
Middle Name:F
Last Name:WALLIS
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 1:2045 FRANKLIN ST
Mailing Address - Street 2:RADIOLOGY DEPARTMENT
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80205-5437
Mailing Address - Country:US
Mailing Address - Phone:303-338-4545
Mailing Address - Fax:
Practice Address - Street 1:2045 FRANKLIN ST
Practice Address - Street 2:RADIOLOGY DEPARTMENT
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80205-5437
Practice Address - Country:US
Practice Address - Phone:303-338-4545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO232132085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01232131Medicaid
002930OtherKAISER-COMMERCIAL NUMBER
CO01232131Medicaid
002930OtherKAISER-COMMERCIAL NUMBER
COCO300449Medicare PIN