Wallace, Gary Wayne

Wallace, Gary Wayne is an individual health care provider with primary practice located at 2295 Coronado Street , Idaho Falls ID 83404. He recently has only one registered license in Allopathic & Osteopathic Physicians / Ophthalmology, which is considered as his primary health care specialty. Wallace, Gary Wayne can be contacted via phone (208) 524-8600.

Contact Information

Primary practice address
2295 Coronado Street Idaho Falls ID 83404
Phone: (208) 524-8600
Fax: (208) 524-8394
Website:
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Health care specialties

SpecialtyCodeLicense #State
Allopathic & Osteopathic Physicians / Ophthalmology 207W00000X M-6226 Idaho

Profile Details

NPI number 1144335290
LBN Legal business name Wallace, Gary Wayne
Credentials Doctor of Medicine (MD)
Entity Individual
Sole proprietor 1 No
Enumeration date Aug 20th, 2006
Last updated May 26th, 2011 - about 13 years ago

1 A sole proprietor/sole proprietorship is an individual, and in that capacity, is qualified for a solitary NPI number. The sole proprietor have to apply for the NPI number using his or her own particular Social Security Number (SSN), instead of Employer Identification Number (EIN) regardless of whether he/she has an EIN.

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Identifiers

StateTypeNumberIssuer
All States NPI 1144335290 NPPES
Idaho Other 000010001884 REGENCE BLUE SHIELD
Idaho MEDICAID 002797900 REGENCE BLUE SHIELD
Idaho Other J4449 REGENCE BLUE SHIELD

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