Provider Demographics
NPI:1437352770
Name:WALLACE MANN MD PA
Entity Type:Organization
Organization Name:WALLACE MANN MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:WALLACE
Authorized Official - Middle Name:
Authorized Official - Last Name:MANN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:806-273-7118
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-06
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK6771207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX111983601Medicaid
TX111983603Medicaid
TX111983601Medicaid
TX111983603Medicaid