Individual
MARK E WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1600 23RD AVE, GREELEY, CO 80634-6070
(970) 356-2424
(970) 346-2774
Mailing address
1600 23RD AVE, GREELEY, CO 80634-6070
(970) 356-2424
(970) 346-2774
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
DR32010
CO
207Q00000X
Family Medicine Physician
G056273
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
01320100
—
CO
Enumeration date
10/21/2005
Last updated
12/20/2010
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