Provider Demographics
NPI:1275725384
Name:WALLACE, TIMOTHY R (DO)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:R
Last Name:WALLACE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:855 N WESTHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54904-7668
Mailing Address - Country:US
Mailing Address - Phone:920-303-8700
Mailing Address - Fax:920-303-8832
Practice Address - Street 1:855 N WESTHAVEN DR
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54904-7668
Practice Address - Country:US
Practice Address - Phone:920-303-8700
Practice Address - Fax:920-303-8832
Is Sole Proprietor?:No
Enumeration Date:2007-08-13
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1195207Q00000X
PAOS013436207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1195OtherMEDICAL LICENSE
WI60032-021OtherMEDICAL LICENSE
PAOS013436OtherLICENSE
SC011953Medicaid
SC011953Medicaid