Provider Demographics
NPI:1730591017
Name:WALLACE, JERALD PAYDEN (MD)
Entity type:Individual
Prefix:
First Name:JERALD
Middle Name:PAYDEN
Last Name:WALLACE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 ROSE ST
Mailing Address - Street 2:C246
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40536-0293
Mailing Address - Country:US
Mailing Address - Phone:859-323-6162
Mailing Address - Fax:
Practice Address - Street 1:800 ROSE ST
Practice Address - Street 2:C246
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-0293
Practice Address - Country:US
Practice Address - Phone:859-323-6162
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-21
Last Update Date:2016-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY49437208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery