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NPI Code Detail

MEDICARE: DR. WALLACE BEVERLY MCLEOD III M.D

MEDICARE: DR. WALLACE BEVERLY MCLEOD III M.D
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
1207Q00000XFamily Medicine Physician15393OK

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
11861711731OTHEROKGROUP NPI
215393OTHEROKSTATE LICENSURE

General Provider Information

NPI Number : 1922035237
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. WALLACE BEVERLY MCLEOD III M.D
Provider Business Mailing Address
First Line : 2216 N MARTIN LUTHER KING AVE
Second Line :
City : OKLAHOMA CITY
State : OK
Zip : 73111-2404
Country : US
Telephone Number : 405-424-0111
Fax Number : 405-424-0115
Provider Business Practice Location Address
First Line : 2216 N MARTIN LUTHER KING AVE
Second Line :
City : OKLAHOMA CITY
State : OK
Zip : 73111-2404
Country : US
Telephone Number : 405-424-0111
Fax Number : 405-424-0115
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/26/2006
Last Update Date : 06/19/2014

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