Individual
TIMOTHY R WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
D.O.
Contact information
Practice address
855 N WESTHAVEN DR, OSHKOSH, WI 54904-7668
(920) 303-8700
(920) 303-8832
Mailing address
PO BOX 735044, CHICAGO, IL 60673-5044
(800) 326-2250
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
1195
SC
207Q00000X
Family Medicine Physician
Primary
60032
WI
207Q00000X
Family Medicine Physician
OS013436
PA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
011953
—
SC
05
—
100028993
—
WI
01
—
1195
MEDICAL LICENSE
SC
01
—
60032-021
MEDICAL LICENSE
WI
01
—
OS013436
LICENSE
PA
Enumeration date
08/13/2007
Last updated
04/09/2025
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