Healthcare Provider Details

I. General information

NPI: 1831198811
Provider Name (Legal Business Name): BRIAN DAVID WALLACE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2005
Last Update Date: 10/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 BROOKHAVEN RD
FRANKLIN KY
42134-2746
US

IV. Provider business mailing address

PO BOX 3179
INDIANAPOLIS IN
46206-3179
US

V. Phone/Fax

Practice location:
  • Phone: 317-614-9849
  • Fax: 317-428-1044
Mailing address:
  • Phone: 317-614-9849
  • Fax: 317-428-1044

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number39483
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD0000040992
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: