Active NPI
Brent E Wallace, MD
- Family Medicine Physician
- Roy, UT
National Provider Identifier
1124136221
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Family Medicine Physician
- License
- 771610101205
- Practice address
- 1915 W 5950 S
Roy, UT 84067-1454 - Phone
- (801) 387-8100
- NPI assigned
- Aug 28, 2006
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician | 207Q00000X | 771610101205 | UT | Primary |
Addresses
Primary practice location
1915 W 5950 S
Roy, UT 84067-1454
Mailing address
PO Box 27128
Salt Lake City, UT 84127-0128
Phone (801) 387-8100
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 870348215008 | Medicaid | UT |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 771610101205 | UT | MD | Family Medicine Physician |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| County of Tuolumne | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
-
- Community/Behavioral Health Agency
- Sonora, CA
- NPI 1366618035
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1156723200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1215648000000",
"number": "1124136221",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "PO BOX 27128",
"city": "SALT LAKE CITY",
"state": "UT",
"postal_code": "841270128",
"telephone_number": "801-387-8100"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1915 W 5950 S",
"city": "ROY",
"state": "UT",
"postal_code": "840671454",
"telephone_number": "801-387-8100"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WALLACE",
"first_name": "BRENT",
"middle_name": "E",
"name_prefix": "Dr.",
"credential": "MD",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-08-28",
"last_updated": "2008-07-10",
"status": "A"
},
"taxonomies": [
{
"code": "207Q00000X",
"taxonomy_group": "",
"desc": "Family Medicine",
"state": "UT",
"license": "771610101205",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "870348215008",
"state": "UT"
}
],
"endpoints": [],
"other_names": []
}Other providers in Roy, UT
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 10, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.