Provider Demographics
NPI:1013028612
Name:WALLACE, JASON R (MD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:R
Last Name:WALLACE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12554 RIATA VISTA CIRCLE
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78727-6432
Mailing Address - Country:US
Mailing Address - Phone:512-795-5100
Mailing Address - Fax:512-795-5122
Practice Address - Street 1:12554 RIATA VISTA CIRCLE
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78727-6432
Practice Address - Country:US
Practice Address - Phone:512-795-5100
Practice Address - Fax:512-795-5122
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2018-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000466512085B0100X
TXM97272085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging