Provider Demographics
NPI:1962484733
Name:WALLIS, JACK WESLEY (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:WESLEY
Last Name:WALLIS
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 1:2108 HUNTER RD
Mailing Address - Street 2:SUITE 116
Mailing Address - City:SAN MARCOS
Mailing Address - State:TX
Mailing Address - Zip Code:78666-5156
Mailing Address - Country:US
Mailing Address - Phone:512-754-7700
Mailing Address - Fax:512-754-0012
Practice Address - Street 1:2108 HUNTER RD
Practice Address - Street 2:SUITE 116
Practice Address - City:SAN MARCOS
Practice Address - State:TX
Practice Address - Zip Code:78666-5156
Practice Address - Country:US
Practice Address - Phone:512-754-7700
Practice Address - Fax:512-754-0012
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-17
Last Update Date:2010-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG8488207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX122902302Medicaid
C23132Medicare UPIN
TX122902302Medicaid