Provider Demographics
NPI:1548695075
Name:WALLACE, RYAN MYLES
Entity type:Individual
Prefix:DR
First Name:RYAN
Middle Name:MYLES
Last Name:WALLACE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 LONG WHARF DR STE 321
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-5946
Mailing Address - Country:US
Mailing Address - Phone:203-781-4600
Mailing Address - Fax:203-781-4624
Practice Address - Street 1:55 LOCK ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511
Practice Address - Country:US
Practice Address - Phone:203-432-0290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-03
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT554902084N0400X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008056168Medicaid
CT008076123Medicaid
CT500000315Medicaid
CT004082286Medicaid
CT008022626Medicaid