Healthcare Provider Details

I. General information

NPI: 1205222502
Provider Name (Legal Business Name): STEPHEN BLAKE WALLACE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2015
Last Update Date: 07/29/2020
Certification Date: 07/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3055 ROSLYN ST UNIT 200
DENVER CO
80238-3324
US

IV. Provider business mailing address

10361 E 28TH PL
DENVER CO
80238-3051
US

V. Phone/Fax

Practice location:
  • Phone: 303-724-7378
  • Fax:
Mailing address:
  • Phone: 225-572-6083
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License NumberDR.0063577
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: