Provider Demographics
NPI:1144229600
Name:WALLACE, CHARLES DOUGLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:DOUGLAS
Last Name:WALLACE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:3860 CALLE FORTUNADA
Mailing Address - Street 2:STE #210
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-4802
Mailing Address - Country:US
Mailing Address - Phone:858-309-6303
Mailing Address - Fax:858-309-6301
Practice Address - Street 1:3030 CHILDRENS WAY
Practice Address - Street 2:STE 410
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-4232
Practice Address - Country:US
Practice Address - Phone:858-966-6789
Practice Address - Fax:858-966-8519
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2011-11-02
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Provider Licenses
StateLicense IDTaxonomies
CAG67953207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery