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NPI Code Detail

MEDICARE: MR. BRIAN DAVID WALLACE MD

MEDICARE: MR. BRIAN DAVID WALLACE MD
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
12085R0202XDiagnostic Radiology Physician39483KY
22085R0202XDiagnostic Radiology PhysicianMD0000040992TN

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1831198811
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. BRIAN DAVID WALLACE MD
Provider Business Mailing Address
First Line : PO BOX 3179
Second Line :
City : INDIANAPOLIS
State : IN
Zip : 46206-3179
Country : US
Telephone Number : 317-614-9849
Fax Number : 317-428-1044
Provider Business Practice Location Address
First Line : 1100 BROOKHAVEN RD
Second Line :
City : FRANKLIN
State : KY
Zip : 42134-2746
Country : US
Telephone Number : 317-614-9849
Fax Number : 317-428-1044
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/20/2005
Last Update Date : 10/28/2015

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