Provider Demographics
NPI:1962484634
Name:WALLACE, GARY RHETT (MD, FAAFP)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:RHETT
Last Name:WALLACE
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Gender:M
Credentials:MD, FAAFP
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Mailing Address - Street 1:2817 REILLY RD
Mailing Address - Street 2:WOMACK ARMY MEDICAL CENTER
Mailing Address - City:FORT BRAGG
Mailing Address - State:NC
Mailing Address - Zip Code:28310-7324
Mailing Address - Country:US
Mailing Address - Phone:910-907-8922
Mailing Address - Fax:910-907-6069
Practice Address - Street 1:BLDG 5-4257
Practice Address - Street 2:BASTOGNE EXTENSION
Practice Address - City:FORT BRAGG
Practice Address - State:NC
Practice Address - Zip Code:28310-0001
Practice Address - Country:US
Practice Address - Phone:910-907-9560
Practice Address - Fax:910-907-9818
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-17
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
TXJ8821207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine