1437349479 NPI number — DAVID MICHAEL WALLACE D.O.

Table of content: DAVID MICHAEL WALLACE D.O. (NPI 1437349479)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437349479 NPI number — DAVID MICHAEL WALLACE D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALLACE
Provider First Name:
DAVID
Provider Middle Name:
MICHAEL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1437349479
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/27/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4911 SANDHILL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUGAR LAND
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77479-5320
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-238-7870
Provider Business Mailing Address Fax Number:
281-633-4985

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
22001 SOUTHWEST FWY STE 300
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RICHMOND
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77469-7001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-633-4940
Provider Business Practice Location Address Fax Number:
281-633-4943
Provider Enumeration Date:
07/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  34-008872 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207QS0010X , with the licence number: N0539 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 8BL970 . This is a "BLUE CROSS BLUE SHIELD TX" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com