Provider Demographics
NPI:1710081161
Name:NELMS, WALLACE R JR (MD)
Entity Type:Individual
Prefix:DR
First Name:WALLACE
Middle Name:R
Last Name:NELMS
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 1:2546 WARD BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27893
Mailing Address - Country:US
Mailing Address - Phone:252-399-0707
Mailing Address - Fax:252-291-7079
Practice Address - Street 1:2546 WARD BOULEVARD
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893
Practice Address - Country:US
Practice Address - Phone:252-399-0707
Practice Address - Fax:252-291-7079
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2015-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20830207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC62099OtherBCBS OF NC
NC8962099Medicaid
NC62099OtherBCBS OF NC
E16432Medicare UPIN