Provider Demographics
NPI:1356335285
Name:WALLACE, TERRY W (MD)
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:W
Last Name:WALLACE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:700 E MOREHEAD ST STE 300
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28202-2742
Mailing Address - Country:US
Mailing Address - Phone:704-334-7800
Mailing Address - Fax:704-414-7512
Practice Address - Street 1:700 E MOREHEAD ST STE 300
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28202-2742
Practice Address - Country:US
Practice Address - Phone:704-334-7800
Practice Address - Fax:704-414-7512
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2017-12-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME1184052085R0202X
KY476352085R0202X
OK313212085R0202X
ARE-93052085R0202X
VA01012563302085R0202X
SC206052085R0202X
NC274112085R0202X
TN497342085R0202X
MS236632085R0202X
GA0714272085R0202X
MO20150143962085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8985523Medicaid
NC8985523Medicaid
NC212854Medicare ID - Type Unspecified