Provider Demographics
NPI:1598792293
Name:WALLACE, ROBERT BRUCE III (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:BRUCE
Last Name:WALLACE
Suffix:III
Gender:M
Credentials:MD
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Mailing Address - Street 1:4110 PARLIAMENT DR
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71303-2717
Mailing Address - Country:US
Mailing Address - Phone:318-448-4488
Mailing Address - Fax:318-448-9731
Practice Address - Street 1:4110 PARLIAMENT DR
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71303-2717
Practice Address - Country:US
Practice Address - Phone:318-448-4488
Practice Address - Fax:318-448-9731
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2007-07-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
LA012846207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1191710Medicaid
LA5M658Medicare ID - Type UnspecifiedMCR PROVIDER NUMBER
LA1191710Medicaid