Provider Demographics
NPI:1336173574
Name:WALLACE, HEATHER MORGAN (MD)
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:MORGAN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 14459
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31416-1459
Mailing Address - Country:US
Mailing Address - Phone:912-790-4000
Mailing Address - Fax:912-790-4407
Practice Address - Street 1:230 E DERENNE AVE
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-6736
Practice Address - Country:US
Practice Address - Phone:912-790-4000
Practice Address - Fax:912-790-4407
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2016-01-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MS18108208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00857566Medicaid
MSP00462352OtherRR MEDICARE
GA003131576DMedicaid
MS00857566Medicaid