Provider Demographics
NPI:1922035237
Name:MCLEOD, WALLACE BEVERLY III (MD)
Entity Type:Individual
Prefix:DR
First Name:WALLACE
Middle Name:BEVERLY
Last Name:MCLEOD
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2216 N MARTIN LUTHER KING AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73111-2404
Mailing Address - Country:US
Mailing Address - Phone:405-424-0111
Mailing Address - Fax:405-424-0115
Practice Address - Street 1:2216 N MARTIN LUTHER KING AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73111-2404
Practice Address - Country:US
Practice Address - Phone:405-424-0111
Practice Address - Fax:405-424-0115
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-26
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK15393207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1861711731OtherGROUP NPI
OK15393OtherSTATE LICENSURE
OK1861711731OtherGROUP NPI