Provider Demographics
NPI:1740219369
Name:WALLACE, PATRICK JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:JOSEPH
Last Name:WALLACE
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 1:2240 GULF FWY S STE 2.100
Mailing Address - Street 2:
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573-5143
Mailing Address - Country:US
Mailing Address - Phone:832-505-1800
Mailing Address - Fax:
Practice Address - Street 1:2240 GULF FWY S STE 2.100
Practice Address - Street 2:
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573-5143
Practice Address - Country:US
Practice Address - Phone:832-505-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ7243208600000X, 2086X0206X, 2086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8S4802OtherBLUE CROSS/BLUE SHIELD
P00229401OtherMEDICARE RAILROAD
TX041937602Medicaid
TX8S4802OtherBLUE CROSS/BLUE SHIELD