Provider Demographics
NPI:1831198811
Name:WALLACE, BRIAN DAVID (MD)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:DAVID
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:PO BOX 3179
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-3179
Mailing Address - Country:US
Mailing Address - Phone:317-614-9849
Mailing Address - Fax:317-428-1044
Practice Address - Street 1:1100 BROOKHAVEN RD
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:KY
Practice Address - Zip Code:42134-2746
Practice Address - Country:US
Practice Address - Phone:317-614-9849
Practice Address - Fax:317-428-1044
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY394832085R0202X
TNMD00000409922085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64113905Medicaid
KY64113905Medicaid
KYK015310Medicare PIN
KY0352605Medicare ID - Type Unspecified