Provider Demographics
NPI:1659370070
Name:CARTER, WALLACE R JR (MD)
Entity Type:Individual
Prefix:
First Name:WALLACE
Middle Name:R
Last Name:CARTER
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:PO BOX 2697
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42102-7697
Mailing Address - Country:US
Mailing Address - Phone:270-745-1467
Mailing Address - Fax:270-745-1417
Practice Address - Street 1:825 2ND AVE STE B1
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-1790
Practice Address - Country:US
Practice Address - Phone:270-796-3330
Practice Address - Fax:270-796-3338
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-18
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY31183208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64311830Medicaid
G05072Medicare UPIN
KY0566701Medicare ID - Type Unspecified