Provider Demographics
NPI:1770787566
Name:WALLACE, LUCY BROOKS (MD)
Entity type:Individual
Prefix:
First Name:LUCY
Middle Name:BROOKS
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 COLLIER ROAD NW
Mailing Address - Street 2:SUITE 470
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309
Mailing Address - Country:US
Mailing Address - Phone:404-351-1002
Mailing Address - Fax:404-350-8290
Practice Address - Street 1:275 COLLIER ROAD NW
Practice Address - Street 2:SUITE 470
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309
Practice Address - Country:US
Practice Address - Phone:404-351-1002
Practice Address - Fax:404-350-8290
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN4832208600000X, 2086S0127X, 2086X0206X
GA77806208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
No2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003193207AMedicaid