Provider Demographics
NPI:1922441880
Name:WALLACE, SCOTT MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:MICHAEL
Last Name:WALLACE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:780 KUENZLI ST
Mailing Address - Street 2:STE 202
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-0845
Mailing Address - Country:US
Mailing Address - Phone:775-982-5262
Mailing Address - Fax:775-982-5496
Practice Address - Street 1:75 PRINGLE WAY
Practice Address - Street 2:STE 300
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-1464
Practice Address - Country:US
Practice Address - Phone:775-982-5000
Practice Address - Fax:775-982-3900
Is Sole Proprietor?:No
Enumeration Date:2013-04-10
Last Update Date:2016-09-01
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NV16487208000000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
13804974OtherCAQH