Healthcare Provider Details

I. General information

NPI: 1396162673
Provider Name (Legal Business Name): STEPHEN J WALLACE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2014
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4250 MERCANTILE DR
LAKE OSWEGO OR
97035-2504
US

IV. Provider business mailing address

PO BOX 42928
BELFAST ME
04915-1281
US

V. Phone/Fax

Practice location:
  • Phone: 503-850-9940
  • Fax: 503-850-6709
Mailing address:
  • Phone: 503-850-9940
  • Fax: 844-749-4220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD206048
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD60932486
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License NumberMD206048
License Number StateOR
# 4
Primary TaxonomyN
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License NumberDR.0078412
License Number StateCO
# 5
Primary TaxonomyN
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License NumberMD60932486
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: