Individual
MAX LEE WALLACE JR.
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
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
Update your record
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