MEDICARE: R. DUNCAN WALLACE, M.D., P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	148121-1205	UT

General Provider Information

NPI Number	:	1700120334
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	R. DUNCAN WALLACE, M.D., P.C.

Provider Business Mailing Address
First Line	:	PO BOX 581065
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84158-1065
Country	:	US
Telephone Number	:	801-355-8323
Fax Number	:

Provider Business Practice Location Address
First Line	:	2972 S DEVONSHIRE CIR
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84108-2526
Country	:	US
Telephone Number	:	801-355-8323
Fax Number	:

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MS. KATHY SNOW
Credential	:
Telephone Number	:	801-486-7940

Provider Enumeration Date	:	11/20/2012
Last Update Date	:	04/09/2013

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