Provider Demographics
NPI:1063499267
Name:WALLACE, GRAHAM WILSON (MD)
Entity Type:Individual
Prefix:DR
First Name:GRAHAM
Middle Name:WILSON
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:DAVID GRANT MEDICAL CENTER
Mailing Address - Street 2:101 BODIN CIRCLE
Mailing Address - City:TRAVIS AFB
Mailing Address - State:CA
Mailing Address - Zip Code:94535-1809
Mailing Address - Country:US
Mailing Address - Phone:707-423-3040
Mailing Address - Fax:
Practice Address - Street 1:DAVID GRANT MEDICAL CENTER
Practice Address - Street 2:101 BODIN CIRCLE
Practice Address - City:TRAVIS AFB
Practice Address - State:CA
Practice Address - Zip Code:94535-1809
Practice Address - Country:US
Practice Address - Phone:707-423-3040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2022-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01051128A207Q00000X, 2085R0202X
CAC1422172085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine