Provider Demographics
NPI:1861489049
Name:WALLIS, MARK S (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:S
Last Name:WALLIS
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 1:3535 N FOURTH ST STE 400
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-0038
Mailing Address - Country:US
Mailing Address - Phone:903-757-3881
Mailing Address - Fax:903-757-5948
Practice Address - Street 1:3535 N FOURTH ST STE 400
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-0038
Practice Address - Country:US
Practice Address - Phone:903-757-3881
Practice Address - Fax:903-757-5948
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH6685207N00000X, 207ND0900X, 207NI0002X, 207NP0225X, 207NS0135X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207NI0002XAllopathic & Osteopathic PhysiciansDermatologyClinical & Laboratory Dermatological Immunology
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX30076724OtherDPS NUMBER
TX45D0684764OtherCLIA NUMBER
TXCID037095OtherCIDC NUMBER
TXH6685OtherMEDICAL LICENSE NUMBER
TX04813881913OtherMED. ED. NUMBER
TX0898678-03Medicaid
TX0898678-03Medicaid
TX8881B0Medicare ID - Type Unspecified
TX30076724OtherDPS NUMBER
TX0898678-03Medicaid