Provider Demographics
NPI:1437184017
Name:WALLACE, WILLIAM H
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:H
Last Name:WALLACE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1421 N STATE ST # ST.1
Mailing Address - Street 2:STE. 504
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-1658
Mailing Address - Country:US
Mailing Address - Phone:601-969-9050
Mailing Address - Fax:601-354-2443
Practice Address - Street 1:1421 N STATE ST # ST.1
Practice Address - Street 2:STE. 504
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-1658
Practice Address - Country:US
Practice Address - Phone:601-969-9050
Practice Address - Fax:601-354-2443
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS6475173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSB31169Medicare UPIN