Provider Demographics
NPI:1457526808
Name:WALLACE, JOHN II (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:WALLACE
Suffix:II
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 1:1705 GARDNER DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28405-8873
Mailing Address - Country:US
Mailing Address - Phone:910-343-5300
Mailing Address - Fax:910-254-1352
Practice Address - Street 1:1705 GARDNER DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28405-8873
Practice Address - Country:US
Practice Address - Phone:910-343-5300
Practice Address - Fax:910-254-1352
Is Sole Proprietor?:No
Enumeration Date:2008-04-28
Last Update Date:2015-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC98015462084P0800X
NC98-015462084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5920117Medicaid
H49054Medicare UPIN
NC5920117Medicaid