Individual
DOUGLAS W WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
2300 MANCHESTER EXPY, STE A001, COLUMBUS, GA 31904-6802
(706) 257-7700
(706) 257-7708
Mailing address
P.O. BOX 9145, COLUMBUS, GA 31908-9145
(706) 257-7700
(706) 257-7708
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
Primary
014966
GA
2085R0202X
Diagnostic Radiology Physician
14966
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
003139318A
—
GA
05
—
141177
—
AL
01
—
202I307506
MEDICARE PTAN
GA
Enumeration date
09/07/2005
Last updated
07/27/2015
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