Provider Demographics
NPI:1013058932
Name:WALLACE, DOUGLAS MCKAY (MD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:MCKAY
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 1:11104 SW 139TH CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-3251
Mailing Address - Country:US
Mailing Address - Phone:305-387-7346
Mailing Address - Fax:305-387-4632
Practice Address - Street 1:1201 NW 16TH ST
Practice Address - Street 2:MIAMI VA MEDICAL CENTER, DEPT OF NEUROLOGY
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33125-1624
Practice Address - Country:US
Practice Address - Phone:305-575-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME946432084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology