Provider Demographics
NPI:1689648636
Name:CHAMPLAIN, WALLACE JACKSON (DO)
Entity Type:Individual
Prefix:
First Name:WALLACE
Middle Name:JACKSON
Last Name:CHAMPLAIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 E DOWNING SUITE 208
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-3363
Mailing Address - Country:US
Mailing Address - Phone:918-456-2496
Mailing Address - Fax:918-456-7108
Practice Address - Street 1:1500 E DOWNING ST STE 208
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-3234
Practice Address - Country:US
Practice Address - Phone:918-456-2496
Practice Address - Fax:918-456-7108
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1994207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100118860AMedicaid
OK100118860AMedicaid