Active NPI
Robert B Wallace, MD
- Internal Medicine Physician
- Iowa City, IA
National Provider Identifier
1417920711
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Internal Medicine Physician
- License
- 18838
- Practice address
- 200 Hawkins Dr
Iowa City, IA 52242-1009 - Phone
- (319) 384-5005
- Fax
- (319) 384-5004
- NPI assigned
- Feb 8, 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 |
|---|---|---|---|---|
| Internal Medicine Physician | 207R00000X | 18838 | IA | Primary |
Addresses
Primary practice location
200 Hawkins Dr
Iowa City, IA 52242-1009
Mailing address
200 Hawkins Dr
Iowa City, IA 52242-1009
Phone (319) 384-5005
Other identifiers 2
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 095539 | Medicaid | IA | |
| 09553 | Other | IA | WELLMARK BCBS |
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)
- Not enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 18838 | IA | MD | Pharmacotherapy Pharmacist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1139356800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1198022400000",
"number": "1417920711",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "200 HAWKINS DR",
"city": "IOWA CITY",
"state": "IA",
"postal_code": "522421009",
"telephone_number": "319-384-5005",
"fax_number": "319-384-5004"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "200 HAWKINS DR",
"city": "IOWA CITY",
"state": "IA",
"postal_code": "522421009",
"telephone_number": "319-384-5005",
"fax_number": "319-384-5004"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WALLACE",
"first_name": "ROBERT",
"middle_name": "B",
"credential": "MD",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-02-08",
"last_updated": "2007-12-19",
"status": "A"
},
"taxonomies": [
{
"code": "207R00000X",
"taxonomy_group": "",
"desc": "Internal Medicine",
"state": "IA",
"license": "18838",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "095539",
"state": "IA"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "WELLMARK BCBS",
"identifier": "09553",
"state": "IA"
}
],
"endpoints": [],
"other_names": []
}Other providers in Iowa City, IA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 19, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.