MEDICARE: DR. JAMES DAVID WALLACE M.D.

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	208600000X	Surgery Physician	MD60918669	WA
2	2086S0127X	Trauma Surgery Physician	MD49240	DC

General Provider Information

NPI Number	:	1730490277
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAMES DAVID WALLACE M.D.

Provider Business Mailing Address
First Line	:	BLDG H 2005 KNIGHT LANE
Second Line	:	ATTN: MEDICAL STAFF SERVICES
City	:	JACKSONVILLE
State	:	FL
Zip	:	32212-0140
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	34800 BOB WILSON DR
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92134-1894
Country	:	US
Telephone Number	:	619-532-7575
Fax Number	:

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

Provider Enumeration Date	:	06/30/2010
Last Update Date	:	08/11/2025

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