Provider Demographics
NPI:1750355020
Name:DONALDSON, WALLACE ALVIN (MD)
Entity type:Individual
Prefix:DR
First Name:WALLACE
Middle Name:ALVIN
Last Name:DONALDSON
Suffix:
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 1:102 6TH ST
Mailing Address - Street 2:
Mailing Address - City:ZILLAH
Mailing Address - State:WA
Mailing Address - Zip Code:98953-9442
Mailing Address - Country:US
Mailing Address - Phone:509-829-5699
Mailing Address - Fax:509-829-6366
Practice Address - Street 1:102 6TH ST
Practice Address - Street 2:
Practice Address - City:ZILLAH
Practice Address - State:WA
Practice Address - Zip Code:98953-9442
Practice Address - Country:US
Practice Address - Phone:509-829-5699
Practice Address - Fax:509-829-6366
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-14
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00009019208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1531508Medicaid
WAG000119084Medicare ID - Type Unspecified
WAA06546Medicare UPIN