Provider Demographics
NPI:1184654709
Name:WALLACE, DEBORAH I (MD)
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:I
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3840 RUCKRIEGEL PKWY
Mailing Address - Street 2:SUITE 105
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40299-6835
Mailing Address - Country:US
Mailing Address - Phone:502-261-7227
Mailing Address - Fax:844-965-9615
Practice Address - Street 1:3840 RUCKRIEGEL PKWY
Practice Address - Street 2:SUITE 105
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40299-6835
Practice Address - Country:US
Practice Address - Phone:502-261-7227
Practice Address - Fax:844-965-9615
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY39992208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics