Marshall W. Wallace, MD

Primary specialty

Surgery PhysicianTaxonomy code 208600000X

License

14168058-1205 Issued in UT

Practice address

30 N Mario Capecchi Dr RM 4S100
Salt Lake City, UT 84112-0002

Phone

(801) 581-2121

NPI assigned

Mar 22, 2023

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in UT

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1679443200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1727740800000",
    "number": "1154024974",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "30 N MARIO CAPECCHI DR RM 4S100",
            "city": "SALT LAKE CITY",
            "state": "UT",
            "postal_code": "841120002",
            "telephone_number": "801-581-2121"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "30 N MARIO CAPECCHI DR RM 4S100",
            "city": "SALT LAKE CITY",
            "state": "UT",
            "postal_code": "841120002",
            "telephone_number": "801-581-2121"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "MARSHALL",
        "middle_name": "W.",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2023-03-22",
        "last_updated": "2024-10-01",
        "certification_date": "2024-09-27",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "208600000X",
            "taxonomy_group": "",
            "desc": "Surgery",
            "state": "UT",
            "license": "14168058-1205",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Jennifer Wallace
• John Mark Wallace, R.PH.
• Justice Kassidy Wallace
• Laney Wallace
• Mark Spangler Wallace, DDS
• Rebecca Wallace, APRN
• Robert Duncan Wallace, M.D.
• Sara Elizabeth Wallace, DPT
• Rachel Jo Wallenda
• Brynn Wallentine

• Surgery Physician in Salt Lake City, UT
• Providers in Salt Lake City, UT by specialty
• Surgery Physician in Utah

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 1, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.