Individual
MARK R. WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1400 E KINCAID ST, MOUNT VERNON, WA 98274-4127
(360) 848-4150
(360) 428-6485
Mailing address
1400 E KINCAID ST, ATTN: CREDENTIALING, MOUNT VERNON, WA 98274-4127
(360) 428-2500
(360) 428-6485
Taxonomy
Speciality
Code
Description
License number
State
207RI0200X
Infectious Disease Physician
Primary
MD00020591
WA
207RI0200X
Infectious Disease Physician
ME94199
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
2039554
—
WA
05
—
275105400
—
FL
Enumeration date
01/11/2006
Last updated
02/28/2017
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