Provider Demographics
NPI:1821153529
Name:DUNCAN, WALLACE (MD)
Entity Type:Individual
Prefix:DR
First Name:WALLACE
Middle Name:
Last Name:DUNCAN
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 924583
Mailing Address - Street 2:
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30010-4583
Mailing Address - Country:US
Mailing Address - Phone:770-987-8400
Mailing Address - Fax:770-987-8494
Practice Address - Street 1:5900 HILLANDALE DR
Practice Address - Street 2:ANNEX E
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-3802
Practice Address - Country:US
Practice Address - Phone:770-987-8400
Practice Address - Fax:770-987-8494
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-25
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA041109207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00687893GMedicaid
GA00687893GMedicaid
GA11BDTHFMedicare ID - Type Unspecified