Individual
WALLACE FORD MARTIN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
631 PROFESSIONAL DRIVE, SUITE 300, LAWRENCEVILLE, GA 30046-3371
(770) 962-9977
(770) 339-9804
Mailing address
631 PROFESSIONAL DRIVE, SUITE 300, LAWRENCEVILLE, GA 30046-3371
(770) 962-9977
(770) 339-9804
Taxonomy
Speciality
Code
Description
License number
State
208600000X
Surgery Physician
Primary
026153
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00301914A
—
GA
01
—
GRP1797
MEDICARE GROUP NUMBER
GA
Enumeration date
07/07/2005
Last updated
09/01/2010
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