Mark S Wallis, M.D.

Primary specialty

MOHS-Micrographic Surgery PhysicianTaxonomy code 207ND0101X

License

H6685 Issued in TX

Practice address

3535 N Fourth St Ste 400
Longview, TX 75605-0038

Phone

(903) 757-3881

Fax

(903) 757-5948

NPI assigned

Oct 3, 2005

Sex

Male

Sole proprietor

Yes

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

Specialties & licenses 6

Addresses

Other identifiers 6

Medicare fee-for-service enrollment

Enrolled in TX

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

Specialty

Dermatology

Education

University of Texas Medical School at San Antonio, 1988

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Wallis Dermatology Associates PLLCGroup PAC ID 0749440188, 11 clinicians

Practice addresses (Care Compare)

Merit-based Incentive Payment System (MIPS)

Final score

75 of 100Reported as individual

Procedures performed for Medicare patients

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

Practice roles

Locations

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.

• Wallis Dermatology Associates PLLC

  • Dermatology Physician
  • Longview, TX
  • NPI 1396945234
  Medicare reassignment Care Compare group NPD
• Deborah K Phillips Mdpa

  • Specialist
  • Lexington, KY
  • NPI 1588677835
  NPD (past)

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

{
    "created_epoch": "1128297600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1678147200000",
    "number": "1861489049",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3535 N FOURTH ST STE 400",
            "city": "LONGVIEW",
            "state": "TX",
            "postal_code": "756050038",
            "telephone_number": "903-757-3881",
            "fax_number": "903-757-5948"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3535 N FOURTH ST STE 400",
            "city": "LONGVIEW",
            "state": "TX",
            "postal_code": "756050038",
            "telephone_number": "903-757-3881",
            "fax_number": "903-757-5948"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLIS",
        "first_name": "MARK",
        "middle_name": "S",
        "name_prefix": "Dr.",
        "credential": "M.D.",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2005-10-03",
        "last_updated": "2023-03-07",
        "certification_date": "2021-07-21",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "",
            "desc": "Dermatology",
            "state": "TX",
            "license": "H6685",
            "primary": false
        },
        {
            "code": "207ND0900X",
            "taxonomy_group": "",
            "desc": "Dermatology, Dermatopathology",
            "state": "TX",
            "license": "H6685",
            "primary": false
        },
        {
            "code": "207NI0002X",
            "taxonomy_group": "",
            "desc": "Dermatology, Clinical & Laboratory Dermatological Immunology",
            "state": "TX",
            "license": "H6685",
            "primary": false
        },
        {
            "code": "207NP0225X",
            "taxonomy_group": "",
            "desc": "Dermatology, Pediatric Dermatology",
            "state": "TX",
            "license": "H6685",
            "primary": false
        },
        {
            "code": "207NS0135X",
            "taxonomy_group": "",
            "desc": "Dermatology, Procedural Dermatology",
            "state": "TX",
            "license": "H6685",
            "primary": false
        },
        {
            "code": "207ND0101X",
            "taxonomy_group": "",
            "desc": "Dermatology, MOHS-Micrographic Surgery",
            "state": "TX",
            "license": "H6685",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "DPS NUMBER",
            "identifier": "30076724",
            "state": "TX"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CLIA NUMBER",
            "identifier": "45D0684764",
            "state": "TX"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CIDC NUMBER",
            "identifier": "CID037095",
            "state": "TX"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICAL LICENSE NUMBER",
            "identifier": "H6685",
            "state": "TX"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MED. ED. NUMBER",
            "identifier": "04813881913",
            "state": "TX"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0898678-03",
            "state": "TX"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Kimberley R Wallace, LCDC
• Sharon Wallace
• Wendy Jo Wallace, RDN
• Wallis Dermatology Associates PLLC
• Luke Stewart Wallis, MD
• April Elaine Walnofer, DO
• Maureen Walston
• Valenitta Walter Sneed
• Shawn Walter, LPC
• Justin Curtis Ward, O.D.

• MOHS-Micrographic Surgery Physician in Longview, TX
• Providers in Longview, TX by specialty
• MOHS-Micrographic Surgery Physician in Texas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 7, 2023; 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.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.