Provider Demographics
NPI:1780614529
Name:WALLACE, ERIC LEE (MD)
Entity type:Individual
Prefix:DR
First Name:ERIC
Middle Name:LEE
Last Name:WALLACE
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 1:140 W 7TH ST
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-1726
Mailing Address - Country:US
Mailing Address - Phone:931-783-5515
Mailing Address - Fax:931-783-5513
Practice Address - Street 1:145 W 4TH ST STE 201
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-2476
Practice Address - Country:US
Practice Address - Phone:931-783-5515
Practice Address - Fax:931-783-5513
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2025-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN71205208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ096326Medicaid
I55281Medicare UPIN
2053141Medicare PIN