Provider Demographics
NPI:1265475206
Name:WALLACE, TRACEY C (MD)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:C
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 1:1121 JOHNSON FERRY RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30068-5425
Mailing Address - Country:US
Mailing Address - Phone:770-509-1025
Mailing Address - Fax:
Practice Address - Street 1:3525 PIEDMONT RD NE
Practice Address - Street 2:BLDG 7-601
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30305-1578
Practice Address - Country:US
Practice Address - Phone:770-509-1025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA042483207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00777697AMedicaid
GA00777697AMedicaid
GAG46640Medicare UPIN