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Individual
DR. ROY TRENT WALLACE
Active
Individual
DR. ROY TRENT WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Taxonomy
Speciality
Code
Description
License number
State
207W00000X
Ophthalmology Physician
30794
KY
207W00000X
Ophthalmology Physician
MD0000023587
TN
207WX0107X
Retina Specialist (Ophthalmology) Physician
Primary
MD0000023587
TN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
3069202
—
TN
01
—
3379053
MEDICARE/GROUP
TN
05
—
64914617
—
KY
Enumeration date
10/14/2005
Last updated
12/01/2017
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