Individual
EMMETT LEE WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
DO
Contact information
Practice address
1019 BROADLAWN AVENUE, BETTENDORF, IA 52722
(563) 359-1181
(563) 386-3177
Mailing address
1019 BROADLAWN AVENUE, BETTENDORF, IA 52722
(563) 359-1181
(563) 386-3177
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
01133
IA
207Q00000X
Family Medicine Physician
03652892
IL
207Q00000X
Family Medicine Physician
27754
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0047902
—
IA
01
—
0158642
BCBS
—
Enumeration date
04/20/2006
Last updated
07/22/2011
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