Provider Demographics
NPI:1972585156
Name:WALLACE, JOHN HUGH G JR (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:HUGH G
Last Name:WALLACE
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:MR
Other - First Name:HUGH
Other - Middle Name:G
Other - Last Name:WALLACE
Other - Suffix:JR
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:NAVAL AMBULATORY CARE CENTER
Mailing Address - Street 2:ROUTE 12, BLDG 449, ATTN: PROFESSIONAL AFFAIRS
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06349-5600
Mailing Address - Country:US
Mailing Address - Phone:860-694-2377
Mailing Address - Fax:860-694-2590
Practice Address - Street 1:NAVAL AMBULATORY CARE CENTER
Practice Address - Street 2:ROUTE 12, BLDG 449, ATTN: PROFESSIONAL AFFAIRS
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06349-5600
Practice Address - Country:US
Practice Address - Phone:860-694-2377
Practice Address - Fax:860-694-2590
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810002367103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN