Provider Demographics
NPI:1922327485
Name:WALLACE, HENRY C (MD)
Entity Type:Individual
Prefix:
First Name:HENRY
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 1:800 FAIR PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72204-1720
Mailing Address - Country:US
Mailing Address - Phone:501-604-6900
Mailing Address - Fax:
Practice Address - Street 1:301 SOUTHRIDGE BLVD STE A
Practice Address - Street 2:
Practice Address - City:HEBER SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:72543
Practice Address - Country:US
Practice Address - Phone:501-206-0176
Practice Address - Fax:501-206-0179
Is Sole Proprietor?:No
Enumeration Date:2010-05-24
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN4831207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1922327485OtherNPI
AR188382001Medicaid
AR188382001Medicaid