Healthcare Provider Details

I. General information

NPI: 1366438384
Provider Name (Legal Business Name): WALLACE LEE TRACY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2005
Last Update Date: 09/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1940 S WHITEHEAD DR
DE WITT AR
72042-2906
US

IV. Provider business mailing address

1940 S WHITEHEAD DR PO BOX 471
DE WITT AR
72042-2906
US

V. Phone/Fax

Practice location:
  • Phone: 870-946-4505
  • Fax: 870-946-2428
Mailing address:
  • Phone: 870-946-4505
  • Fax: 870-946-2428

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC7340
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: