Provider Demographics
NPI:1437349479
Name:WALLACE, DAVID MICHAEL (DO)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:MICHAEL
Last Name:WALLACE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4911 SANDHILL DR
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77479-5320
Mailing Address - Country:US
Mailing Address - Phone:281-238-7870
Mailing Address - Fax:281-633-4985
Practice Address - Street 1:22001 SOUTHWEST FWY STE 300
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:TX
Practice Address - Zip Code:77469-7001
Practice Address - Country:US
Practice Address - Phone:281-633-4940
Practice Address - Fax:281-633-4943
Is Sole Proprietor?:No
Enumeration Date:2007-07-26
Last Update Date:2020-02-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH34-008872207Q00000X
TXN0539207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8BL970OtherBLUE CROSS BLUE SHIELD TX
TX8BL970OtherBLUE CROSS BLUE SHIELD TX
OTH001Medicare UPIN