Individual
DR. DOUGLAS CHARLES WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
3900 ST FRANCIS WAY, STE 201, LAFAYETTE, IN 47905-4923
(765) 446-7981
(765) 446-7982
Mailing address
3900 ST FRANCIS WAY, STE 201, LAFAYETTE, IN 47905-4923
(765) 446-7981
(765) 446-7982
Taxonomy
Speciality
Code
Description
License number
State
208G00000X
Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
Primary
01071946A
IN
208G00000X
Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
036-101410
IL
208G00000X
Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
G66727
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036112410
—
IL
Enumeration date
11/06/2006
Last updated
12/19/2012
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