Provider Demographics
NPI:1275701963
Name:WALLACE, AARON JACK (MD)
Entity Type:Individual
Prefix:DR
First Name:AARON
Middle Name:JACK
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:PO BOX 1960
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72403-1960
Mailing Address - Country:US
Mailing Address - Phone:870-936-8523
Mailing Address - Fax:870-934-3633
Practice Address - Street 1:4802 E JOHNSON AVE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-6007
Practice Address - Country:US
Practice Address - Phone:870-936-8523
Practice Address - Fax:870-934-3633
Is Sole Proprietor?:No
Enumeration Date:2008-02-14
Last Update Date:2014-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD428274207X00000X
ARE-6150207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR179031001Medicaid
AR5H582OtherBCBS
AR5H956Medicare PIN