Provider Demographics
NPI:1326036856
Name:MANN, WALLACE (MD)
Entity Type:Individual
Prefix:MR
First Name:WALLACE
Middle Name:
Last Name:MANN
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 1:202 S MCGEE ST
Mailing Address - Street 2:
Mailing Address - City:BORGER
Mailing Address - State:TX
Mailing Address - Zip Code:79007-4022
Mailing Address - Country:US
Mailing Address - Phone:806-273-7118
Mailing Address - Fax:806-274-6070
Practice Address - Street 1:202 S MCGEE ST
Practice Address - Street 2:
Practice Address - City:BORGER
Practice Address - State:TX
Practice Address - Zip Code:79007-4022
Practice Address - Country:US
Practice Address - Phone:806-273-7118
Practice Address - Fax:806-274-6070
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK6771207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX111983601Medicaid
G50558Medicare UPIN
TX00826LMedicare PIN