Individual
DR. GARY WAYNE WALLACE
Active
Individual
DR. GARY WAYNE WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
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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