Provider Demographics
NPI:1114988995
Name:BROWN, WALLACE HAROLD II (MD)
Entity Type:Individual
Prefix:DR
First Name:WALLACE
Middle Name:HAROLD
Last Name:BROWN
Suffix:II
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:W.
Other - Middle Name:HAROLD
Other - Last Name:BROWN
Other - Suffix:II
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2210 LINE AVE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104-2152
Mailing Address - Country:US
Mailing Address - Phone:318-221-9671
Mailing Address - Fax:318-425-2343
Practice Address - Street 1:2210 LINE AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104-2152
Practice Address - Country:US
Practice Address - Phone:318-221-9671
Practice Address - Fax:318-425-2343
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA011630208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1385344Medicaid
LAD79341Medicare UPIN
LA5J441B255Medicare ID - Type Unspecified