Basic Information
| Provider Information | |||||||||
| NPI: | 1790736122 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALLENTINE | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1055 N 500 W | ||||||||
| Address2: | ATTN: CREDENTIALING | ||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846043305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013548225 | ||||||||
| FaxNumber: | 8014180941 | ||||||||
| Practice Location | |||||||||
| Address1: | 1055 N 500 W | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846043305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013742367 | ||||||||
| FaxNumber: | 8014298015 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 02/12/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 60986311205 | UT | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 87028102800B | 01 | UT | EMIA | OTHER | 870281028000 | 05 | UT | MEDICAID | 88780 | 01 | UT | PEHP | OTHER | 933849 | 01 | UT | DMBA | OTHER | P00345446 | 01 | UT | PALMETTO | OTHER | I62333 | 01 | UT | UPIN | OTHER | 36-00187 | 01 | UT | UHC | OTHER | 107046686101 | 01 | UT | IHC | OTHER | 285195 | 01 | UT | ALTIUS | OTHER | 6098631120000 | 01 | UT | BCBS | OTHER |