Provider Demographics
NPI:1801864327
Name:WALLACE, JAMES C (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:C
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 1:834 SHERIDAN ST
Mailing Address - Street 2:
Mailing Address - City:PORT TOWNSEND
Mailing Address - State:WA
Mailing Address - Zip Code:98368-2443
Mailing Address - Country:US
Mailing Address - Phone:360-385-2200
Mailing Address - Fax:
Practice Address - Street 1:834 SHERIDAN ST
Practice Address - Street 2:
Practice Address - City:PORT TOWNSEND
Practice Address - State:WA
Practice Address - Zip Code:98368-2443
Practice Address - Country:US
Practice Address - Phone:136-038-5220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00028714207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8128357Medicaid
1126WAOtherREGENCE BLUE SHIELD RIDER
820000117OtherRAILROAD MEDICARE