Provider Demographics
NPI:1700327061
Name:WALLACE, DAVID WARNER (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:WARNER
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 1:2108 E THOMAS RD
Mailing Address - Street 2:STE 130
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-7761
Mailing Address - Country:US
Mailing Address - Phone:602-933-3124
Mailing Address - Fax:
Practice Address - Street 1:1919 E THOMAS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-7710
Practice Address - Country:US
Practice Address - Phone:602-933-0000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-19
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA158148207L00000X
AZ67086207LP3000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP3000XAllopathic & Osteopathic PhysiciansAnesthesiologyPediatric AnesthesiologyGroup - Single Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty