Healthcare Provider Details

I. General information

NPI: 1679641666
Provider Name (Legal Business Name): THOMAS M WALLACE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 FLORIDA AVE
MODESTO CA
95350-4405
US

IV. Provider business mailing address

1441 FLORIDA AVE
MODESTO CA
95350-4405
US

V. Phone/Fax

Practice location:
  • Phone: 209-576-3525
  • Fax: 209-576-3544
Mailing address:
  • Phone: 209-576-3525
  • Fax: 209-576-3544

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberG42269
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: