Provider Demographics
NPI:1841289022
Name:WALLACE, STEPHANIE R (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:R
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2 S CASCADE AVE STE 140
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80903-1604
Mailing Address - Country:US
Mailing Address - Phone:719-866-6568
Mailing Address - Fax:719-538-2999
Practice Address - Street 1:2405 RESEARCH PARKWAY
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918
Practice Address - Country:US
Practice Address - Phone:719-522-1134
Practice Address - Fax:719-598-7229
Is Sole Proprietor?:No
Enumeration Date:2005-10-19
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0034435208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01344357Medicaid
COCX7698Medicare PIN
COG12025Medicare UPIN