Provider Demographics
NPI:1881730687
Name:WALLACE, CANDICE E (MD)
Entity type:Individual
Prefix:MRS
First Name:CANDICE
Middle Name:E
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:CANDICE
Other - Middle Name:WALLACE
Other - Last Name:DIGGS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1260 WILDCLIFF CIR NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329-3473
Mailing Address - Country:US
Mailing Address - Phone:678-442-3317
Mailing Address - Fax:678-442-4416
Practice Address - Street 1:1000 MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-7694
Practice Address - Country:US
Practice Address - Phone:678-442-3317
Practice Address - Fax:678-442-4416
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA030918207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00405468DMedicaid
GAE34330Medicare UPIN
GA00405468DMedicaid