# DAVID W WALLACE

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- **Entity:** Individual
- **Status:** Active
- **Sole proprietor:** No

## Provider details

- **NPI number:** 1376532168
- **Gender:** Man
- **Credential:** MD MBA

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | 22054 | KY | Yes |

## Other

- **Enumeration date:** 10/14/2005
- **Last updated:** 07/21/2022

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 000000048268 | ANTHEM | KY |
| 01 | — | 0100487 | UHC | — |
| 05 | — | 64220544 | — | KY |
| 01 | — | P00872496 | RR MEDICARE | KY |