Provider Demographics
NPI:1659635472
Name:WALLACE, MESHIA KERRY-ANN (MD)
Entity Type:Individual
Prefix:DR
First Name:MESHIA
Middle Name:KERRY-ANN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2412 VILLAGE PROFESSIONAL DR S
Mailing Address - Street 2:
Mailing Address - City:OPELIKA
Mailing Address - State:AL
Mailing Address - Zip Code:36801-4742
Mailing Address - Country:US
Mailing Address - Phone:334-528-6670
Mailing Address - Fax:334-528-6671
Practice Address - Street 1:2412 VILLAGE PROFESSIONAL DR S
Practice Address - Street 2:
Practice Address - City:OPELIKA
Practice Address - State:AL
Practice Address - Zip Code:36801
Practice Address - Country:US
Practice Address - Phone:334-528-6670
Practice Address - Fax:334-528-6671
Is Sole Proprietor?:No
Enumeration Date:2012-06-26
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005647207R00000X
AL36982207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL219026Medicaid