Healthcare Provider Details

I. General information

NPI: 1851710354
Provider Name (Legal Business Name): JAMES WALLACE JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2014
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

263 FARMINGTON AVE
FARMINGTON CT
06030-8063
US

IV. Provider business mailing address

263 FARMINGTON AVE UCONN PROVIDER ENROLLMENT MC 8082
FARMINGTON CT
06030-8082
US

V. Phone/Fax

Practice location:
  • Phone: 860-679-8080
  • Fax: 860-679-1430
Mailing address:
  • Phone: 860-679-8080
  • Fax: 860-679-1430

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 TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number086045
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: