Individual
DR. MICHAEL C. WALLIS
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
100 MARIO CAPECCHI DR, SALT LAKE CITY, UT 84113-1103
(801) 662-5555
Mailing address
PO BOX 413035, SALT LAKE CITY, UT 84141-3035
(801) 213-3900
Taxonomy
Speciality
Code
Description
License number
State
208800000X
Urology Physician
Primary
6078212-1205
UT
2088P0231X
Pediatric Urology Physician
M-13870
ID
Other
Enumeration date
07/25/2006
Last updated
12/16/2021
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