Healthcare Provider Details

I. General information

NPI: 1295807733
Provider Name (Legal Business Name): THOMAS WITHERSPOON WALLACE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 06/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10100 KANIS RD
LITTLE ROCK AR
72205-6202
US

IV. Provider business mailing address

1807 SHADOW LN
LITTLE ROCK AR
72207-2015
US

V. Phone/Fax

Practice location:
  • Phone: 501-255-6000
  • Fax: 501-255-6400
Mailing address:
  • Phone: 501-747-2124
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License NumberE-6988
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: