Healthcare Provider Details

I. General information

NPI: 1558384388
Provider Name (Legal Business Name): MICHAEL C. WALLIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 12/16/2021
Certification Date: 12/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MARIO CAPECCHI DR
SALT LAKE CITY UT
84113-1103
US

IV. Provider business mailing address

PO BOX 413035
SALT LAKE CITY UT
84141-3035
US

V. Phone/Fax

Practice location:
  • Phone: 801-662-5555
  • Fax:
Mailing address:
  • Phone: 801-213-3900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number6078212-1205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License NumberM-13870
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: