Provider Demographics
NPI:1700120334
Name:R. DUNCAN WALLACE, M.D., P.C.
Entity Type:Organization
Organization Name:R. DUNCAN WALLACE, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:SNOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-486-7940
Mailing Address - Street 1:PO BOX 581065
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84158-1065
Mailing Address - Country:US
Mailing Address - Phone:801-355-8323
Mailing Address - Fax:
Practice Address - Street 1:2972 S DEVONSHIRE CIR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108-2526
Practice Address - Country:US
Practice Address - Phone:801-355-8323
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-20
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT148121-12052084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty