Provider Demographics
NPI:1740371699
Name:WALLACE, BETHANY ANN (DO)
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:ANN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:DO
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Mailing Address - Street 1:558 E CASTLE PINES PKWY PMB 151
Mailing Address - Street 2:
Mailing Address - City:CASTLE ROCK
Mailing Address - State:CO
Mailing Address - Zip Code:80108-4608
Mailing Address - Country:US
Mailing Address - Phone:719-365-6421
Mailing Address - Fax:710-365-6408
Practice Address - Street 1:8890 N UNION BLVD STE 170
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-2701
Practice Address - Country:US
Practice Address - Phone:719-365-6421
Practice Address - Fax:719-365-6408
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2023-05-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CO27638207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D24975Medicare UPIN