Healthcare Provider Details

I. General information

NPI: 1306945829
Provider Name (Legal Business Name): MATHEW CARY WALLACE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MATHEW CARY WALLACK MD

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 08/01/2024
Certification Date: 08/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4228 LOMAC ST STE 2
MONTGOMERY AL
36106-2929
US

IV. Provider business mailing address

4228 LOMAC ST STE 2
MONTGOMERY AL
36106-2929
US

V. Phone/Fax

Practice location:
  • Phone: 919-928-2351
  • Fax:
Mailing address:
  • Phone: 919-928-2351
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P2900X
TaxonomyPain Medicine (Psychiatry & Neurology) Physician
License NumberMD.29202
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: