Provider Demographics
NPI:1740208693
Name:CHRISTY, WALLACE (MD)
Entity Type:Individual
Prefix:
First Name:WALLACE
Middle Name:
Last Name:CHRISTY
Suffix:
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 593
Mailing Address - Street 2:
Mailing Address - City:GRASS LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49240-0593
Mailing Address - Country:US
Mailing Address - Phone:517-783-3675
Mailing Address - Fax:
Practice Address - Street 1:111 N HURON ST
Practice Address - Street 2:SUITE #203
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-2676
Practice Address - Country:US
Practice Address - Phone:734-547-7900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301056148207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine