Provider Demographics
NPI:1942465356
Name:WALLACE, LAILUN (MD)
Entity Type:Individual
Prefix:DR
First Name:LAILUN
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:LAILUN
Other - Middle Name:KAMAL
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:13677 W MCDOWELL RD
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85395-2635
Mailing Address - Country:US
Mailing Address - Phone:718-308-6075
Mailing Address - Fax:
Practice Address - Street 1:5227 E CAREFREE HWY
Practice Address - Street 2:
Practice Address - City:CAVE CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85331-9173
Practice Address - Country:US
Practice Address - Phone:602-824-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-24
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301093013207P00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine