Provider Demographics
NPI:1164422481
Name:WALLACE, CHARLES ALAN (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:ALAN
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 1:17110 DALLAS PKWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75248-1167
Mailing Address - Country:US
Mailing Address - Phone:972-380-7090
Mailing Address - Fax:972-380-7016
Practice Address - Street 1:17110 DALLAS PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75248-1167
Practice Address - Country:US
Practice Address - Phone:972-380-7090
Practice Address - Fax:972-380-7016
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG38852086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXC23118Medicare UPIN