Provider Demographics
NPI:1376922948
Name:WALLACE, MICHAEL TAYLOR (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:TAYLOR
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 1:1700 SPRING HILL AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36604-1416
Mailing Address - Country:US
Mailing Address - Phone:251-435-1200
Mailing Address - Fax:
Practice Address - Street 1:1720 SPRING HILL AVE STE 300
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36604-1409
Practice Address - Country:US
Practice Address - Phone:251-435-1200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-28
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN59163207W00000X
AL41653207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology