Provider Demographics
NPI:1225087562
Name:WALLACE, WILLIAM E (DO)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:E
Last Name:WALLACE
Suffix:
Gender:M
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:PO BOX 2078
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:TX
Mailing Address - Zip Code:76234-6156
Mailing Address - Country:US
Mailing Address - Phone:817-380-6621
Mailing Address - Fax:
Practice Address - Street 1:2000 BEN MERRITT DR
Practice Address - Street 2:SUITE B
Practice Address - City:DECATUR
Practice Address - State:TX
Practice Address - Zip Code:76234-3848
Practice Address - Country:US
Practice Address - Phone:817-380-6621
Practice Address - Fax:817-380-6622
Is Sole Proprietor?:No
Enumeration Date:2006-05-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF7282208600000X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX115246411Medicaid
TX8GH312OtherBCBSTX
TXPENDINGMedicare PIN
TX8J7070Medicare PIN
TXA67763Medicare UPIN
TX115246406Medicaid
TX8J7069Medicare PIN
TX115246404Medicaid
TXTXB122056Medicare PIN
TX115246408Medicaid
TX8528B9Medicare PIN