Provider Demographics
NPI:1689623142
Name:WALLIS, VICKI JO (MD)
Entity Type:Individual
Prefix:MRS
First Name:VICKI
Middle Name:JO
Last Name:WALLIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:829 RIVERBEND DR
Mailing Address - Street 2:
Mailing Address - City:GADSDEN
Mailing Address - State:AL
Mailing Address - Zip Code:35901-2556
Mailing Address - Country:US
Mailing Address - Phone:256-546-4611
Mailing Address - Fax:256-546-2214
Practice Address - Street 1:829 RIVERBEND DR
Practice Address - Street 2:
Practice Address - City:GADSDEN
Practice Address - State:AL
Practice Address - Zip Code:35901-2556
Practice Address - Country:US
Practice Address - Phone:256-546-4611
Practice Address - Fax:256-546-2214
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL22626208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL114331Medicaid
H17754Medicare UPIN