Healthcare Provider Details

I. General information

NPI: 1427098102
Provider Name (Legal Business Name): MARK S WALLACE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 08/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UCSD MEDICAL CENTER 200 WEST ARBOR DRIVE MC 0801
SAN DIEGO CA
92103
US

IV. Provider business mailing address

PO BOX 232410
SAN DIEGO CA
92193-2410
US

V. Phone/Fax

Practice location:
  • Phone: 619-543-5720
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberG72906
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberG72906
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: