Healthcare Provider Details

I. General information

NPI: 1437545761
Provider Name (Legal Business Name): WALLACE LOCK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2015
Last Update Date: 04/04/2024
Certification Date: 04/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 S 12TH ST
FORT SMITH AR
72901-4702
US

IV. Provider business mailing address

111 N 1ST ST
HUGHES AR
72348-9100
US

V. Phone/Fax

Practice location:
  • Phone: 479-424-3193
  • Fax:
Mailing address:
  • Phone: 901-481-0927
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberE-10064
License Number StateAR
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number67669
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: