Provider Demographics
NPI:1750560579
Name:WALLACE, GENEVIEVE REBECCA (MD)
Entity type:Individual
Prefix:DR
First Name:GENEVIEVE
Middle Name:REBECCA
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:JENNY
Other - Middle Name:REBECCA
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1056 S 88TH ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:CO
Mailing Address - Zip Code:80027-9460
Mailing Address - Country:US
Mailing Address - Phone:303-442-6647
Mailing Address - Fax:303-442-2696
Practice Address - Street 1:1056 S 88TH ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:CO
Practice Address - Zip Code:80027-9460
Practice Address - Country:US
Practice Address - Phone:303-442-6647
Practice Address - Fax:303-442-2696
Is Sole Proprietor?:No
Enumeration Date:2007-10-29
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO57122207ZD0900X
CODR.0057122207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathology