Basic Information
| Provider Information | |||||||||
| NPI: | 1063419000 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALLACE | ||||||||
| FirstName: | CARMEL | ||||||||
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| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 138 LEADER AVE, OFFICE 241 | ||||||||
| Address2: | UNIVERSITY OF KENTUCKY, DEPARTMENT OF PEDIATRICS | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405069983 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593231432 | ||||||||
| FaxNumber: | 8593233499 | ||||||||
| Practice Location | |||||||||
| Address1: | 138 LEADER AVE, OFFICE 241 | ||||||||
| Address2: | UNIVERSITY OF KENTUCKY, DEPARTMENT OF PEDIATRICS | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405069983 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593231432 | ||||||||
| FaxNumber: | 8593233499 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2005 | ||||||||
| LastUpdateDate: | 12/18/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 18479 | KY | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 64184799 | 05 | KY | MEDICAID |