Provider Demographics
NPI:1164467320
Name:WALLACE, JOHN GEORGE JR (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:GEORGE
Last Name:WALLACE
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4401 W MEMORIAL RD
Mailing Address - Street 2:SUITE 121
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73134-1785
Mailing Address - Country:US
Mailing Address - Phone:405-751-4664
Mailing Address - Fax:405-751-3183
Practice Address - Street 1:4101 TORRANCE BLVD
Practice Address - Street 2:EM DEPT
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-4607
Practice Address - Country:US
Practice Address - Phone:310-540-7676
Practice Address - Fax:405-751-3183
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG45690207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G456900Medicaid
CAA50147Medicare UPIN
CAWG45690DMedicare ID - Type Unspecified