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General NPI Number Information
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NPI Number | 1396162673
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Entity Type | Individual
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Provider Name | STEPHEN J WALLACE MD
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Gender | Male
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Dates
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Enumeration Date | 03/24/2014
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Last Update Date | 01/08/2026
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Provider Practice Location Address
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Address Line | 4103 MERCANTILE DR
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City | LAKE OSWEGO
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State | OR
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Zip | 97035-2556
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Country | US
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Telephone | 503-850-9940
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Fax | 503-850-6709
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Provider Business Mailing Address
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Address Line | 4103 MERCANTILE DR
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City | LAKE OSWEGO
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State | OR
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Zip | 97035-2556
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Country | US
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Telephone | 503-850-9940
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Fax | 503-850-6709
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207XX0801X
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Taxonomy Name | Orthopaedic Trauma Physician
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License Number | MD60932486
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License Number State | WA
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Taxonomy #2
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | MD206048
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License Number State | OR
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Taxonomy #3
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Taxonomy Code | 207XX0801X
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Taxonomy Name | Orthopaedic Trauma Physician
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License Number | MD206048
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License Number State | OR
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Taxonomy #4
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | MD60932486
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License Number State | WA
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