Provider Demographics
NPI:1881622314
Name:ANDERSON, WALLACE STEVE (DO)
Entity type:Individual
Prefix:
First Name:WALLACE
Middle Name:STEVE
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1311 OCILLA RD
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31533-2213
Mailing Address - Country:US
Mailing Address - Phone:912-384-1043
Mailing Address - Fax:
Practice Address - Street 1:1311 OCILLA RD
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-2213
Practice Address - Country:US
Practice Address - Phone:912-384-1043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-30
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA028708207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000325663AMedicaid
GA000325663AMedicaid
D39295Medicare UPIN
080170553Medicare PIN