Individual
GREGORY WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
D.O.
Contact information
Practice address
11050 MOUNT BELVEDERE BLVD, FORT DRUM, NY 13602
(315) 772-5662
Mailing address
11050 MOUNT BELVEDERE BLVD, FORT DRUM, NY 13602-5438
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
02004547A
IN
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Enumeration date
06/27/2013
Last updated
07/27/2018
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