Individual
MAX LEE WALLACE JR.
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
40 HART ST, SUITE B1, NEW BRITAIN, CT 06052-1743
(860) 229-2059
(860) 229-8495
Mailing address
40 HART ST, SUITE B1, NEW BRITAIN, CT 06052-1743
(860) 229-2059
(860) 229-8495
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
Primary
023301
CT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
001233014
—
CT
01
—
010023301CT13
ANTHEM BC/BS
CT
01
—
010026126CT03
ANTHEM BC/BS
CT
01
—
010026126CT04
ANTHEM BC/BS
CT
01
—
010026126CT07
ANTHEM BC/BS
CT
01
—
010026126CT12
ANTHEM BC/BS
CT
01
—
010026126CT14
ANTHEM BC/BS
CT
05
—
1588624282
—
CT
01
—
300023202
RAILROAD MEDICARE
CT
01
—
300106345
RAILROAD MEDICARE
CT
01
—
300117749
RAILROAD MEDICARE
CT
Enumeration date
03/25/2006
Last updated
05/20/2008
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