Provider Demographics
NPI:1487651386
Name:MARTIN, WALLACE FORD (MD)
Entity Type:Individual
Prefix:
First Name:WALLACE
Middle Name:FORD
Last Name:MARTIN
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 1:631 PROFESSIONAL DRIVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-3371
Mailing Address - Country:US
Mailing Address - Phone:770-962-9977
Mailing Address - Fax:770-339-9804
Practice Address - Street 1:631 PROFESSIONAL DRIVE
Practice Address - Street 2:SUITE 300
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-3371
Practice Address - Country:US
Practice Address - Phone:770-962-9977
Practice Address - Fax:770-339-9804
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA026153208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP1797OtherMEDICARE GROUP NUMBER
GA00301914AMedicaid
GA00301914AMedicaid