MEDICARE: DAVID MICHAEL WALLACE D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207QS0010X	Sports Medicine (Family Medicine) Physician	N0539	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	8BL970	OTHER	TX	BLUE CROSS BLUE SHIELD TX

General Provider Information

NPI Number	:	1437349479
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVID MICHAEL WALLACE D.O.

Provider Business Mailing Address
First Line	:	18123 UPPER BAY RD
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77058-3875
Country	:	US
Telephone Number	:	713-363-9090
Fax Number	:	281-333-2490

Provider Business Practice Location Address
First Line	:	18123 UPPER BAY RD STE 200
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77058-3875
Country	:	US
Telephone Number	:	281-363-9090
Fax Number	:	281-333-2490

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/26/2007
Last Update Date	:	06/08/2026

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