Individual
DR. MICHAEL ROBERT WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DPM
Contact information
Practice address
2800 N OAK ST, VALDOSTA, GA 31602-1716
(229) 244-1211
(229) 244-2721
Mailing address
2800 N OAK ST, VALDOSTA, GA 31602-1716
(229) 244-1211
(229) 244-2721
Taxonomy
Speciality
Code
Description
License number
State
213ES0103X
Foot & Ankle Surgery Podiatrist
Primary
599
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
000480029131
—
GA
Enumeration date
10/02/2006
Last updated
09/18/2013
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