Provider Demographics
NPI:1801337134
Name:WALLACE, ROBERT WILLIAM II
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:WILLIAM
Last Name:WALLACE
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 N SILVER MAPLE DR
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70458-5483
Mailing Address - Country:US
Mailing Address - Phone:504-554-2131
Mailing Address - Fax:
Practice Address - Street 1:5000 HENNESSY BLVD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4375
Practice Address - Country:US
Practice Address - Phone:225-765-4050
Practice Address - Fax:225-765-4046
Is Sole Proprietor?:No
Enumeration Date:2017-03-20
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LA326195207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program