Individual
JEFFREY LEIGH WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
411 N SECTION ST, FAIRHOPE, AL 36532-2649
(251) 928-9090
(251) 990-0520
Mailing address
104 PINETOP CIRCLE, FAIRHOPE, AL 36532
(251) 725-2050
Taxonomy
Speciality
Code
Description
License number
State
2083P0011X
Undersea and Hyperbaric Medicine (Preventive Medicine) Physician
29105
AL
208600000X
Surgery Physician
Primary
29105
AL
208D00000X
General Practice Physician
MD29105
AL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1407812001
—
AL
05
—
1548262108
—
AL
05
—
3-187746
—
TN
Enumeration date
08/12/2005
Last updated
10/10/2016
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