Individual
DR. MARK S WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
UCSD MEDICAL CENTER, 200 WEST ARBOR DRIVE MC 0801, SAN DIEGO, CA 92103
(619) 543-5720
Mailing address
PO BOX 232410, SAN DIEGO, CA 92193-2410
Taxonomy
Speciality
Code
Description
License number
State
207L00000X
Anesthesiology Physician
G72906
CA
207LP2900X
Pain Medicine (Anesthesiology) Physician
Primary
G72906
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00G729060
—
CA
Enumeration date
06/08/2006
Last updated
08/21/2018
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