Healthcare Provider Details

I. General information

NPI: 1730591017
Provider Name (Legal Business Name): JERALD PAYDEN WALLACE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2014
Last Update Date: 07/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 ROSE ST C246
LEXINGTON KY
40536-0293
US

IV. Provider business mailing address

800 ROSE ST C246
LEXINGTON KY
40536-0293
US

V. Phone/Fax

Practice location:
  • Phone: 859-323-6162
  • Fax:
Mailing address:
  • Phone: 859-323-6162
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number49437
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: