Individual
BRADLEY WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
1400 E BOULDER ST STE 500, COLORADO SPRINGS, CO 80909-5533
(719) 364-6487
Mailing address
2695 ROCKY MOUNTAIN AVE STE 150, LOVELAND, CO 80538-9071
(719) 364-6487
Taxonomy
Speciality
Code
Description
License number
State
208600000X
Surgery Physician
Primary
DR.0063071
CO
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Enumeration date
04/17/2013
Last updated
06/23/2022
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