Provider Demographics
NPI:1629089156
Name:WALLACE, JEFFREY S (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:S
Last Name:WALLACE
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:PO BOX 2108
Mailing Address - Street 2:
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75087-5008
Mailing Address - Country:US
Mailing Address - Phone:972-463-1253
Mailing Address - Fax:972-463-0758
Practice Address - Street 1:6800 HERITAGE PKWY STE 102
Practice Address - Street 2:
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75087-8746
Practice Address - Country:US
Practice Address - Phone:972-463-1253
Practice Address - Fax:214-607-1641
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ3932207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
G23087Medicare UPIN
8361B6Medicare ID - Type Unspecified