Provider Demographics
NPI:1184842627
Name:WALLACE, WILLIAM ARTHUR JR (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:ARTHUR
Last Name:WALLACE
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:1679 EAGLE HARBOR PKWY
Mailing Address - Street 2:SUITE C
Mailing Address - City:FLEMING ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32003-4815
Mailing Address - Country:US
Mailing Address - Phone:904-348-0727
Mailing Address - Fax:904-621-9272
Practice Address - Street 1:1679 EAGLE HARBOR PKWY
Practice Address - Street 2:SUITE C
Practice Address - City:FLEMING ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32003-4815
Practice Address - Country:US
Practice Address - Phone:904-348-0727
Practice Address - Fax:904-621-9272
Is Sole Proprietor?:No
Enumeration Date:2007-04-22
Last Update Date:2015-11-01
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Provider Licenses
StateLicense IDTaxonomies
FLME1077492086S0122X
OH35.0796322086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery