Provider Demographics
NPI:1942294426
Name:PROPHET, WALLACE DALE (MD)
Entity Type:Individual
Prefix:
First Name:WALLACE
Middle Name:DALE
Last Name:PROPHET
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 1:350 HERITAGE WAY
Mailing Address - Street 2:SUITE 2100
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-3158
Mailing Address - Country:US
Mailing Address - Phone:406-257-8992
Mailing Address - Fax:406-755-4161
Practice Address - Street 1:350 HERITAGE WAY
Practice Address - Street 2:SUITE 2100
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-3158
Practice Address - Country:US
Practice Address - Phone:406-257-8992
Practice Address - Fax:406-755-4161
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2017-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL9734207RP1001X
MT49643207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000012909Medicaid
GA00284468AMedicaid
FL068414700Medicaid
GA00284468AMedicaid
AL000012909Medicare ID - Type UnspecifiedMEDICARE PROVIDER #