MEDICARE: DOUGLAS W WALLACE MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician	14966	GA
2	2085R0202X	Diagnostic Radiology Physician	014966	GA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	202I307506	OTHER	GA	MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1083608053
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOUGLAS W WALLACE MD

Provider Business Mailing Address
First Line	:	P.O. BOX 9145
Second Line	:
City	:	COLUMBUS
State	:	GA
Zip	:	31908-9145
Country	:	US
Telephone Number	:	706-257-7700
Fax Number	:	706-257-7708

Provider Business Practice Location Address
First Line	:	2300 MANCHESTER EXPY
Second Line	:	STE A001
City	:	COLUMBUS
State	:	GA
Zip	:	31904-6802
Country	:	US
Telephone Number	:	706-257-7700
Fax Number	:	706-257-7708

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/07/2005
Last Update Date	:	07/27/2015

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Directions to “ DOUGLAS W WALLACE MD” Practice Location

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