Provider Demographics
NPI:1861711731
Name:WALLACE B. MCLEOD III, INC
Entity type:Organization
Organization Name:WALLACE B. MCLEOD III, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JESSIE
Authorized Official - Middle Name:MAE
Authorized Official - Last Name:SHAMBRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-424-0111
Mailing Address - Street 1:2216 N MARTIN LUTHER KING AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73111-2445
Mailing Address - Country:US
Mailing Address - Phone:405-424-0111
Mailing Address - Fax:405-424-0115
Practice Address - Street 1:2216 N MARTIN LUTHER KING AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73111-2445
Practice Address - Country:US
Practice Address - Phone:405-424-0111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-18
Last Update Date:2010-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK15393170100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes170100000XOther Service ProvidersMedical Genetics, Ph.D. Medical GeneticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK05538623602Medicaid
OKC46581Medicare UPIN