Provider Demographics
NPI:1861977415
Name:WALLACE BLAKE MCKINNEY MEDICAL GROUP OF CALIFORNIA
Entity type:Organization
Organization Name:WALLACE BLAKE MCKINNEY MEDICAL GROUP OF CALIFORNIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:DUTTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:916-215-4554
Mailing Address - Street 1:3513 BRIGHTON BLVD STE 230
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80216-3606
Mailing Address - Country:US
Mailing Address - Phone:916-215-4554
Mailing Address - Fax:
Practice Address - Street 1:9245 LAGUNA SPRINGS DR STE 200
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758-7991
Practice Address - Country:US
Practice Address - Phone:916-215-4554
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-29
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty