Healthcare Provider Details

I. General information

NPI: 1225292634
Provider Name (Legal Business Name): JOHN WALLACE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2008
Last Update Date: 08/11/2025
Certification Date: 08/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9321 W THOMAS RD STE 205
PHOENIX AZ
85037-3392
US

IV. Provider business mailing address

1850 N CENTRAL AVE SUITE 1600
PHOENIX AZ
85004-4527
US

V. Phone/Fax

Practice location:
  • Phone: 866-974-2673
  • Fax: 866-939-2673
Mailing address:
  • Phone: 602-262-8900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number4301093046
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number52631
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number52631
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: