Individual
DR. KENNETH K WALLACE
Active
Sole proprietor
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
3000 ROGERS AVE, FORT SMITH, AR 72901-4232
(479) 782-8892
(479) 782-8840
Mailing address
3000 ROGERS AVE, FORT SMITH, AR 72901-4232
(479) 782-8892
(479) 782-8840
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
R2091
AR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
55462
BCBS
AR
Enumeration date
02/03/2006
Last updated
07/08/2007
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