Healthcare Provider Details

I. General information

NPI: 1144331513
Provider Name (Legal Business Name): WILLIAM W WALLACE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8933 ACTIVITY RD
SAN DIEGO CA
92126-4427
US

IV. Provider business mailing address

8933 ACTIVITY RD
SAN DIEGO CA
92126-4427
US

V. Phone/Fax

Practice location:
  • Phone: 858-653-6170
  • Fax:
Mailing address:
  • Phone: 858-653-6170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License NumberG17502
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: