Provider Demographics
NPI:1205222502
Name:WALLACE, STEPHEN BLAKE (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:BLAKE
Last Name:WALLACE
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 1:10361 E 28TH PL
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80238-3051
Mailing Address - Country:US
Mailing Address - Phone:225-572-6083
Mailing Address - Fax:
Practice Address - Street 1:3055 ROSLYN ST UNIT 200
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80238-3324
Practice Address - Country:US
Practice Address - Phone:303-724-7378
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-13
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0063577207XX0004X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program