Provider Demographics
NPI:1063451144
Name:WALLACE, DOUGLAS C (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:C
Last Name:WALLACE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:DOUGLAS
Other - Middle Name:CRAIG
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:4072 GANTZ RD
Mailing Address - Street 2:
Mailing Address - City:GROVE CITY
Mailing Address - State:OH
Mailing Address - Zip Code:43123-4816
Mailing Address - Country:US
Mailing Address - Phone:614-875-0011
Mailing Address - Fax:614-539-7287
Practice Address - Street 1:4072 GANTZ RD
Practice Address - Street 2:
Practice Address - City:GROVE CITY
Practice Address - State:OH
Practice Address - Zip Code:43123-4816
Practice Address - Country:US
Practice Address - Phone:614-875-0011
Practice Address - Fax:614-539-7287
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.049780207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0586996Medicaid
OH000000019025OtherANTHEM BC/BS
OH15825OtherUNITED HEALTHCARE OF OHIO
E97631Medicare UPIN
OHWA0565525Medicare ID - Type Unspecified