Provider Demographics
NPI:1063464006
Name:WALLACE, JAMES EDWARDS JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:EDWARDS
Last Name:WALLACE
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:1135 EXPRESSWAY DR
Mailing Address - Street 2:SUITE 200 A
Mailing Address - City:PINEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71360-6698
Mailing Address - Country:US
Mailing Address - Phone:318-561-9600
Mailing Address - Fax:318-561-0228
Practice Address - Street 1:1135 EXPRESSWAY DR
Practice Address - Street 2:SUITE 200 A
Practice Address - City:PINEVILLE
Practice Address - State:LA
Practice Address - Zip Code:71360-6698
Practice Address - Country:US
Practice Address - Phone:318-561-9600
Practice Address - Fax:318-561-0228
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2014-06-19
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Provider Licenses
StateLicense IDTaxonomies
LAMD.200134207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1627950Medicaid
LA202768397OtherHUMANA
LA202768397OtherUNITED HEALTHCARE
LA202768397OtherHUMANA MILITARY
LA202768397OtherHUMANA
LA1627950Medicaid