Provider Demographics
NPI:1942292271
Name:WALLACE, LEWIS ALFRED (DO)
Entity Type:Individual
Prefix:
First Name:LEWIS
Middle Name:ALFRED
Last Name:WALLACE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:FRED
Other - Middle Name:
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:1921 STONECIPHER BLVD
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820
Mailing Address - Country:US
Mailing Address - Phone:580-421-4570
Mailing Address - Fax:
Practice Address - Street 1:1921 STONECIPHER BLVD
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820
Practice Address - Country:US
Practice Address - Phone:580-421-4570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3060207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100100370AMedicaid
F41309Medicare UPIN
OK110169662OtherRAILROAD MEDICARE