Provider Demographics
NPI:1881794162
Name:WALLACE, JAMES HOWARD (MD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:HOWARD
Last Name:WALLACE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 N HUMPHREYS BLVD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-2177
Mailing Address - Country:US
Mailing Address - Phone:901-227-8693
Mailing Address - Fax:901-227-8591
Practice Address - Street 1:1600 22ND AVE FL 3
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301
Practice Address - Country:US
Practice Address - Phone:601-693-1055
Practice Address - Fax:601-482-5312
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MST-2618208600000X
MS25034208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08128741Medicaid
GA487562499AMedicaid
SCG13318Medicaid
MST-2618OtherSTATE MEDICAL BOARD
SCG13318Medicaid
Q19957Medicare UPIN
MSAU5009697-2105OtherDEA NUMBER:
GA487562499AMedicaid