Provider Demographics
NPI:1164408043
Name:WALLACE, JEANNE (DO)
Entity Type:Individual
Prefix:DR
First Name:JEANNE
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7557 RAMBLER RD
Mailing Address - Street 2:SUITE 706
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-4142
Mailing Address - Country:US
Mailing Address - Phone:214-369-0800
Mailing Address - Fax:214-378-5311
Practice Address - Street 1:8200 WALNUT HILL LN
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4426
Practice Address - Country:US
Practice Address - Phone:214-345-6789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG4871207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX131346204Medicaid
TX131346201Medicaid
TX88942KMedicare PIN
TX83936KMedicare PIN
TX89122KMedicare PIN
TX131346204Medicaid