Healthcare Provider Details

I. General information

NPI: 1184842627
Provider Name (Legal Business Name): WILLIAM ARTHUR WALLACE JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2007
Last Update Date: 11/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1679 EAGLE HARBOR PKWY SUITE C
FLEMING ISLAND FL
32003-4815
US

IV. Provider business mailing address

1679 EAGLE HARBOR PKWY SUITE C
FLEMING ISLAND FL
32003-4815
US

V. Phone/Fax

Practice location:
  • Phone: 904-348-0727
  • Fax: 904-621-9272
Mailing address:
  • Phone: 904-348-0727
  • Fax: 904-621-9272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License NumberME107749
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number35.079632
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: