Provider Demographics
NPI:1952591828
Name:WALLACE, MARK ALLEN (DO)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALLEN
Last Name:WALLACE
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Gender:M
Credentials:DO
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Mailing Address - Street 1:333 MAGAZINE ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SAULT SAINTE MARIE
Mailing Address - State:MI
Mailing Address - Zip Code:49783-1867
Mailing Address - Country:US
Mailing Address - Phone:906-259-0244
Mailing Address - Fax:906-259-0247
Practice Address - Street 1:333 MAGAZINE ST
Practice Address - Street 2:SUITE 101
Practice Address - City:SAULT SAINTE MARIE
Practice Address - State:MI
Practice Address - Zip Code:49783-1867
Practice Address - Country:US
Practice Address - Phone:906-259-0244
Practice Address - Fax:906-259-0247
Is Sole Proprietor?:No
Enumeration Date:2007-07-27
Last Update Date:2012-10-15
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Provider Licenses
StateLicense IDTaxonomies
MI5101015234207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery