Provider Demographics
NPI:1144353707
Name:WALLACE, SAM A (DO)
Entity type:Individual
Prefix:DR
First Name:SAM
Middle Name:A
Last Name:WALLACE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:341 W PINE ST
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802-4119
Mailing Address - Country:US
Mailing Address - Phone:406-327-0269
Mailing Address - Fax:406-327-0264
Practice Address - Street 1:341 W PINE ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4119
Practice Address - Country:US
Practice Address - Phone:406-327-0269
Practice Address - Fax:406-327-0264
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT8667207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT091831OtherBCBS MT
MT091831OtherBCBS MT