Individual
CATHERINE WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
243 MERCHANTS DR, DALLAS, GA 30132-4700
(770) 230-9967
(770) 445-5860
Mailing address
243 MERCHANTS DR STE A, DALLAS, GA 30132-4749
(404) 543-4506
Taxonomy
Speciality
Code
Description
License number
State
208D00000X
General Practice Physician
Primary
94669
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
8101560001
DME MAC JURISDICTION C
GA
Enumeration date
06/10/2020
Last updated
05/02/2023
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