Active NPI
Weldon Wallace, MD
- Family Medicine Physician
- Grand Rapids, MI
National Provider Identifier
1679550875
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Family Medicine Physician
- License
- 4301085136
- Practice address
- 1260 Ekhart St NE
Grand Rapids, MI 49503-1372 - Phone
- (616) 356-5202
- Fax
- (616) 458-9845
- NPI assigned
- Dec 28, 2005
- 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 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician | 207Q00000X | 4301085136 | MI | Primary |
| Family Medicine Physician | 207Q00000X | 97022 | SC |
Addresses
Primary practice location
1260 Ekhart St NE
Grand Rapids, MI 49503-1372
Mailing address
1260 Ekhart St NE # 112
Grand Rapids, MI 49503-1380
Phone (616) 356-5202
Other practice location 1
PO Box 740013
Atlanta, GA 30374-0013
Phone (833) 804-1695
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 4752504 | Medicaid | MI |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in MI
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: Yes
- Hospice: Yes
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20190121001249 | MI | Order and Referring Only - Family Practice | 3577590967 |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 4301085136 | MI | MD | Family Medicine Physician |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1135728000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1786320000000",
"number": "1679550875",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1260 EKHART ST NE # 112",
"city": "GRAND RAPIDS",
"state": "MI",
"postal_code": "495031380",
"telephone_number": "616-356-5202",
"fax_number": "616-458-9845"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1260 EKHART ST NE",
"city": "GRAND RAPIDS",
"state": "MI",
"postal_code": "495031372",
"telephone_number": "616-356-5202",
"fax_number": "616-458-9845"
}
],
"practiceLocations": [
{
"address_1": "PO Box 740013",
"address_purpose": "LOCATION",
"city": "Atlanta",
"state": "GA",
"postal_code": "303740013",
"country_code": "US",
"telephone_number": "833-804-1695",
"fax_number": "312-929-0373",
"country_name": "United States",
"address_type": "DOM"
}
],
"basic": {
"last_name": "WALLACE",
"first_name": "WELDON",
"credential": "MD",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2005-12-28",
"last_updated": "2026-08-10",
"certification_date": "2026-08-10",
"status": "A"
},
"taxonomies": [
{
"code": "207Q00000X",
"taxonomy_group": "",
"desc": "Family Medicine",
"state": "MI",
"license": "4301085136",
"primary": true
},
{
"code": "207Q00000X",
"taxonomy_group": "",
"desc": "Family Medicine",
"state": "SC",
"license": "97022",
"primary": false
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "4752504",
"state": "MI"
}
],
"endpoints": [],
"other_names": []
}Other providers in Grand Rapids, MI
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 10, 2026; 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.