Provider Demographics
NPI:1346207222
Name:WALLACE, MELANIE (MD)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:845 S MADISON ST
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-4905
Mailing Address - Country:US
Mailing Address - Phone:662-377-5930
Mailing Address - Fax:662-377-5085
Practice Address - Street 1:845 S MADISON ST
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-4905
Practice Address - Country:US
Practice Address - Phone:662-377-5930
Practice Address - Fax:662-377-5085
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS11799207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00114470Medicaid
MSE96918Medicare UPIN
MS00114470Medicaid