Healthcare Provider Details

I. General information

NPI: 1982683603
Provider Name (Legal Business Name): MARK R. WALLACE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2006
Last Update Date: 02/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 E KINCAID ST
MOUNT VERNON WA
98274-4127
US

IV. Provider business mailing address

1400 E KINCAID ST ATTN: CREDENTIALING
MOUNT VERNON WA
98274-4127
US

V. Phone/Fax

Practice location:
  • Phone: 360-848-4150
  • Fax: 360-428-6485
Mailing address:
  • Phone: 360-428-2500
  • Fax: 360-428-6485

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberME94199
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberMD00020591
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: