Provider Demographics
NPI:1972501799
Name:HOLLAND, WALLACE EARL JR (MD)
Entity Type:Individual
Prefix:DR
First Name:WALLACE
Middle Name:EARL
Last Name:HOLLAND
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:10055 FORD AVE
Mailing Address - Street 2:SUITE 5A
Mailing Address - City:RICHMOND HILL
Mailing Address - State:GA
Mailing Address - Zip Code:31324-3972
Mailing Address - Country:US
Mailing Address - Phone:912-756-2020
Mailing Address - Fax:912-756-3187
Practice Address - Street 1:10055 FORD AVE
Practice Address - Street 2:SUITE 5A
Practice Address - City:RICHMOND HILL
Practice Address - State:GA
Practice Address - Zip Code:31324-3972
Practice Address - Country:US
Practice Address - Phone:912-756-2020
Practice Address - Fax:912-756-3187
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA024438207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCG24438Medicaid
GA681687OtherBCBS
GA11BDLDSMedicare ID - Type Unspecified
SCG24438Medicaid