Provider Demographics
NPI:1104850957
Name:WALLACE, JOSEPH CLAUDE (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:CLAUDE
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 1:1031 FAIRFAX PARK
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35406-2807
Mailing Address - Country:US
Mailing Address - Phone:205-345-2211
Mailing Address - Fax:205-345-2220
Practice Address - Street 1:1031 FAIRFAX PARK
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35406-2807
Practice Address - Country:US
Practice Address - Phone:205-345-2211
Practice Address - Fax:205-345-2220
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL10987208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
C71092Medicare UPIN
AL000032059Medicare PIN
020040961Medicare PIN