Provider Demographics
NPI:1083608053
Name:WALLACE, DOUGLAS W (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:W
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:P.O. BOX 9145
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31908-9145
Mailing Address - Country:US
Mailing Address - Phone:706-257-7700
Mailing Address - Fax:706-257-7708
Practice Address - Street 1:2300 MANCHESTER EXPY
Practice Address - Street 2:STE A001
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-6802
Practice Address - Country:US
Practice Address - Phone:706-257-7700
Practice Address - Fax:706-257-7708
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA149662085R0202X
GA0149662085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003139318AMedicaid
AL141177Medicaid
GA202I307506OtherMEDICARE PTAN
GA47BBBFQMedicare ID - Type UnspecifiedMEDICARE