Basic Information
Provider Information
NPI: 1487090098
EntityType: 2
ReplacementNPI:  
OrganizationName: SCOTT C. WALLACE, MD
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
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OtherCredential:  
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Mailing Information
Address1: 8525 GIBBS DR
Address2: SUITE 208
City: SAN DIEGO
State: CA
PostalCode: 921231755
CountryCode: US
TelephoneNumber: 8584950971
FaxNumber: 8584950991
Practice Location
Address1: 8525 GIBBS DR
Address2: SUITE 208
City: SAN DIEGO
State: CA
PostalCode: 921231755
CountryCode: US
TelephoneNumber: 8584950971
FaxNumber: 8584950991
Other Information
ProviderEnumerationDate: 05/22/2013
LastUpdateDate: 05/22/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: WALLACE
AuthorizedOfficialFirstName: SCOTT
AuthorizedOfficialMiddleName: C
AuthorizedOfficialTitleorPosition: PRESIDENT
AuthorizedOfficialTelephone: 8584950971
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: DR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: M.D.
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207L00000XA115766CAY193400000X SINGLE SPECIALTY GROUPAllopathic & Osteopathic PhysiciansAnesthesiology 

No ID Information.


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