Individual
MR. BRIAN DAVID WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1100 BROOKHAVEN RD, FRANKLIN, KY 42134-2746
(317) 614-9849
(317) 428-1044
Mailing address
PO BOX 3179, INDIANAPOLIS, IN 46206-3179
(317) 614-9849
(317) 428-1044
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
Primary
39483
KY
2085R0202X
Diagnostic Radiology Physician
MD0000040992
TN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
64113905
—
KY
Enumeration date
07/20/2005
Last updated
10/28/2015
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