Healthcare Provider Details

I. General information

NPI: 1922327485
Provider Name (Legal Business Name): HENRY C. WALLACE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2010
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2526 HIGHWAY 65 S STE 205
CLINTON AR
72031-6678
US

IV. Provider business mailing address

800 FAIR PARK BLVD
LITTLE ROCK AR
72204-1720
US

V. Phone/Fax

Practice location:
  • Phone: 501-500-3500
  • Fax:
Mailing address:
  • Phone: 501-404-8007
  • Fax: 501-904-3620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberN4831
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: