Provider Demographics
NPI:1538196704
Name:WALLACE, JAMES JOHN (DO)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:JOHN
Last Name:WALLACE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 E EH CRUMP BLVD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38126-5394
Mailing Address - Country:US
Mailing Address - Phone:901-261-2000
Mailing Address - Fax:901-946-9262
Practice Address - Street 1:360 E EH CRUMP BLVD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38126-5394
Practice Address - Country:US
Practice Address - Phone:901-261-2000
Practice Address - Fax:901-946-9262
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI28115-021207Q00000X
TN5182207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30027800Medicaid
WIP00983439OtherRAILROAD MEDICARE
TN5182OtherLICENSE
WI30027800Medicaid