Provider Demographics
NPI:1295749000
Name:WALLACE, LESTER B JR (MD)
Entity type:Individual
Prefix:
First Name:LESTER
Middle Name:B
Last Name:WALLACE
Suffix:JR
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:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-0560
Mailing Address - Fax:704-384-0561
Practice Address - Street 1:1718 E 4TH ST
Practice Address - Street 2:SUITE 201
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-3261
Practice Address - Country:US
Practice Address - Phone:704-384-0560
Practice Address - Fax:704-384-0561
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC21891207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN21891Medicaid
NC8985506Medicaid
NCD33024Medicare UPIN
NC202118CMedicare ID - Type Unspecified
NC202118EMedicare PIN