Provider Demographics
NPI:1649609728
Name:WALLACE, JUSTIN K (DVM)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:K
Last Name:WALLACE
Suffix:
Gender:M
Credentials:DVM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICKASHA
Mailing Address - State:OK
Mailing Address - Zip Code:73018-3420
Mailing Address - Country:US
Mailing Address - Phone:405-224-8023
Mailing Address - Fax:405-224-8024
Practice Address - Street 1:120 S 6TH ST
Practice Address - Street 2:
Practice Address - City:CHICKASHA
Practice Address - State:OK
Practice Address - Zip Code:73018-3420
Practice Address - Country:US
Practice Address - Phone:405-224-8023
Practice Address - Fax:405-224-8024
Is Sole Proprietor?:No
Enumeration Date:2013-11-08
Last Update Date:2013-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5380174M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174M00000XOther Service ProvidersVeterinarian