Individual
DR. GARY WAYNE WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
2295 CORONADO STREET, IDAHO FALLS, ID 83404
(208) 524-8600
(208) 524-8394
Mailing address
2295 CORONADO STREET, IDAHO FALLS, ID 83404
(208) 524-8600
(208) 524-8394
Taxonomy
Speciality
Code
Description
License number
State
207W00000X
Ophthalmology Physician
Primary
M-6226
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010001884
REGENCE BLUE SHIELD
ID
05
—
002797900
—
ID
01
—
J4449
BLUE CROSS
ID
Enumeration date
08/20/2006
Last updated
05/26/2011
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