Healthcare Provider Details

I. General information

NPI: 1952591828
Provider Name (Legal Business Name): MARK ALLEN WALLACE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2007
Last Update Date: 09/03/2025
Certification Date: 09/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 ANCHOR DR STE 102
ROCKPORT ME
04856-3847
US

IV. Provider business mailing address

15 ANCHOR DR STE 102
ROCKPORT ME
04856-3847
US

V. Phone/Fax

Practice location:
  • Phone: 207-301-3660
  • Fax: 207-301-5160
Mailing address:
  • Phone: 207-301-3660
  • Fax: 207-301-5160

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number5101015234
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberDO3910
License Number StateME
# 3
Primary TaxonomyY
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License NumberDO3910
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: