Provider Demographics
NPI:1548262108
Name:WALLACE, JEFFREY LEIGH (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:LEIGH
Last Name:WALLACE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 PINETOP CIRCLE
Mailing Address - Street 2:
Mailing Address - City:FAIRHOPE
Mailing Address - State:AL
Mailing Address - Zip Code:36532
Mailing Address - Country:US
Mailing Address - Phone:251-725-2050
Mailing Address - Fax:
Practice Address - Street 1:411 N SECTION ST
Practice Address - Street 2:
Practice Address - City:FAIRHOPE
Practice Address - State:AL
Practice Address - Zip Code:36532-2649
Practice Address - Country:US
Practice Address - Phone:251-928-9090
Practice Address - Fax:251-990-0520
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL291052083P0011X, 208600000X
ALMD29105208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1407812001Medicaid
AL1548262108Medicaid
TN3-187746Medicaid
AL1407812001Medicaid
TN3-187746Medicare ID - Type Unspecified
B04291Medicare UPIN