Provider Demographics
NPI:1487185054
Name:WALLACE, WILLIAM JR (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:WALLACE
Suffix:JR
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 1:777 HEMLOCK STREET
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201
Mailing Address - Country:US
Mailing Address - Phone:478-633-1891
Mailing Address - Fax:478-633-5153
Practice Address - Street 1:777 HEMLOCK ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201
Practice Address - Country:US
Practice Address - Phone:478-633-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-24
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA86402208600000X, 390200000X
GA009138390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery