Provider Demographics
NPI:1396162673
Name:WALLACE, STEPHEN J (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:J
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 1:4103 MERCANTILE DR
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-2556
Mailing Address - Country:US
Mailing Address - Phone:503-850-9940
Mailing Address - Fax:503-850-6709
Practice Address - Street 1:4103 MERCANTILE DR
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-2556
Practice Address - Country:US
Practice Address - Phone:503-850-9940
Practice Address - Fax:503-850-6709
Is Sole Proprietor?:No
Enumeration Date:2014-03-24
Last Update Date:2021-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60932486207X00000X, 207XX0801X
ORMD206048207XX0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Trauma
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1396162673Medicaid