Provider Demographics
NPI:1780015610
Name:WALLACE, ROBERT G (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:G
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:P.O. BOX 2787
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31902
Mailing Address - Country:US
Mailing Address - Phone:706-323-6485
Mailing Address - Fax:706-596-2025
Practice Address - Street 1:1130 GOAT ROCK ROAD
Practice Address - Street 2:
Practice Address - City:FORTSON
Practice Address - State:GA
Practice Address - Zip Code:31808
Practice Address - Country:US
Practice Address - Phone:706-323-6485
Practice Address - Fax:706-596-2025
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-03
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA133172085N0904X, 2085R0202X, 2085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound