Provider Demographics
NPI:1609804525
Name:WALLACE, DAVID (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:WALLACE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 W LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62220-1900
Mailing Address - Country:US
Mailing Address - Phone:618-233-6044
Mailing Address - Fax:618-233-3287
Practice Address - Street 1:340 W LINCOLN ST
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-1900
Practice Address - Country:US
Practice Address - Phone:618-233-6044
Practice Address - Fax:618-233-3287
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036092919207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0360929191Medicaid
MO107076OtherBCBS MO
2501200OtherSECURE HORIZONS
37099690008OtherGHP
E43629OtherMERCY
12269OtherESSENCE
060046618OtherRR MEDICARE
1734162OtherUHC
MO205943608Medicaid
235649OtherHEALTHLINK
235649OtherWELLCARE
093355OtherHEALTH ALLIANCE
54656OtherCMR
ILP01024928OtherRAILROAD
ILR03182Medicare PIN
E43629OtherMERCY
MO205943608Medicaid