Individual
GREGORY STEPHEN WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1042 MASON WOODS DR NE, ATLANTA, GA 30329-3802
(678) 974-7424
Mailing address
1042 MASON WOODS DR NE, ATLANTA, GA 30329-3802
(678) 974-7424
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
051099
GA
207Q00000X
Family Medicine Physician
G81645
CA
Other
Enumeration date
12/05/2018
Last updated
12/05/2018
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