Provider Demographics
NPI:1770504888
Name:WALLACE, HAROLD JAMES III (MD)
Entity Type:Individual
Prefix:DR
First Name:HAROLD
Middle Name:JAMES
Last Name:WALLACE
Suffix:III
Gender:M
Credentials:MD
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Mailing Address - Street 1:291 MOODY ST
Mailing Address - Street 2:PER SE TECHNOLOGIES
Mailing Address - City:LUDLOW
Mailing Address - State:MA
Mailing Address - Zip Code:01056-1246
Mailing Address - Country:US
Mailing Address - Phone:800-866-6663
Mailing Address - Fax:888-413-1065
Practice Address - Street 1:111 COLCHESTER AVE
Practice Address - Street 2:FLETCHER ALLEN HEALTH CARE DEPT. OF RADIATION ONCOLOGY
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-1473
Practice Address - Country:US
Practice Address - Phone:802-847-3506
Practice Address - Fax:802-847-2386
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
VT042-00099752085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTOVN2161Medicaid
VTOVN2161Medicaid
VN2161Medicare ID - Type Unspecified