Provider Demographics
NPI:1548424898
Name:RICE, JACK WALLACE (DO)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:WALLACE
Last Name:RICE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20044 FM 16 W
Mailing Address - Street 2:
Mailing Address - City:LINDALE
Mailing Address - State:TX
Mailing Address - Zip Code:75771
Mailing Address - Country:US
Mailing Address - Phone:903-882-3808
Mailing Address - Fax:903-882-3808
Practice Address - Street 1:20044 FM 16 W
Practice Address - Street 2:
Practice Address - City:LINDALE
Practice Address - State:TX
Practice Address - Zip Code:75771
Practice Address - Country:US
Practice Address - Phone:903-882-3808
Practice Address - Fax:903-882-3808
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-16
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXC9312207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXA67564Medicare UPIN